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Unipolar depression in adults: Clinical features
Author: Jeffrey M Lyness, MD

Section Editor: Peter P Roy-Byrne, MD
Deputy Editor: David Solomon, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Jan 14, 2017.
INTRODUCTION Depression occurs along a continuum of severity, and depressive syndromes such
as unipolar major depression are heterogeneous [1]. The multiple presentations of major depression stem
in part from the several subtypes that have been identified and the many comorbid disorders that
frequently occur.
This topic reviews the clinical features of depression in adults. The assessment, diagnosis, epidemiology,
neurobiology, treatment, and prognosis of depression in adults are discussed separately, as are the
clinical features and diagnosis of depression in pediatric and older adult patients:
(See "Unipolar depression in adults: Assessment and diagnosis".)

(See "Unipolar depression in adults: Epidemiology, pathogenesis, and neurobiology".)
(See "Unipolar major depression in adults: Choosing initial treatment".)
(See "Unipolar depression in adults: Treatment of resistant depression".)
(See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)
(See "Diagnosis and management of late-life unipolar depression".)
DEFINITIONS OF DEPRESSION It is important to recognize the potential for confusion engendered by

multiple uses of the term depression. Depression may refer to a:
Mood state, which may be normal or part of a psychopathological syndrome

Syndrome, which is a constellation of symptoms and signs (eg, major depression or minor
depression)
Mental disorder that identifies a distinct clinical condition (eg, unipolar major depression)
As an example, major depression is a syndrome that occurs as a consequence of several disorders,

including unipolar major depression (also called major depressive disorder), bipolar disorder,
schizophrenia, substance/medication-induced depressive disorder, and depressive disorder due to
another (general) medical condition [2].
SYMPTOMS
Depressed mood Depressed mood (dysphoria) is an essential feature of unipolar major

depression (major depressive disorder) and persistent depressive disorder (dysthymia) [2]. Dysphoria
can take many forms, such as feeling sad, hopeless, discouraged, blue, or down in the dumps.
Patients who appear sad (eg, tearful) may initially deny sadness and state that they feel anxious,
blah, or have no feelings. In addition, increased and persistent annoyance, frustration, irritability,
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anger, or hostility occurs in roughly 50 percent of patients with major depression [3-5].
Loss of interest or pleasure Loss of interest or pleasure (anhedonia) in formerly pleasurable

activities is also a cardinal symptom of unipolar major depression [2]. Patients experience events,
hobbies, and activities as less interesting or fun, and may report that they dont care anymore.
Patients may withdraw from or lose interest in friends, and libido or interest in sex may decrease as
well.
Change in appetite or weight Appetite and weight may decrease or increase in unipolar major
depression, persistent depressive disorder, and premenstrual dysphoric disorder [2]. Some patients
have to force themselves to eat, whereas others eat more and may crave specific foods (eg, junk
food and carbohydrates).
Sleep disturbance Sleep disturbance frequently occurs in unipolar major depression, and can also
occur in persistent depressive disorder and premenstrual dysphoric disorder [2]. Problems with sleep
manifest as insomnia or hypersomnia:
Initial insomnia Difficulty getting to sleep

Middle insomnia Waking in the middle of the night, with difficulty returning to sleep
Terminal insomnia Waking earlier than usual and remaining awake
Hypersomnia Prolonged nighttime sleep, or daytime sleeping
Many depressed patients describe their sleep as nonrestorative and report difficulty getting out of bed
in the morning.
Fatigue or loss of energy Lack of energy (anergia) is described as feeling tired, exhausted, and
listless. Patients may feel the need to rest during the day, experience heaviness in their limbs, or feel
like it is hard to initiate or complete activities.
Neurocognitive dysfunction Unipolar major depression, persistent depressive disorder, and

premenstrual dysphoric disorder can manifest with impaired ability to think, concentrate, or make
decisions [2,6]. Patients may also appear easily distracted or complain of memory difficulties.
For most depressed patients (especially younger and middle aged adults), cognitive dysfunction is
readily distinguished from that caused by delirium or dementia. Neurocognitive dysfunction in
depression is generally mild, and marked by a greater number of subjective complaints rather than
objective findings. In older adult patients, memory problems may be mistaken for dementia
(pseudodementia); these problems often abate with successful treatment of the depressive
syndrome [2]. However, some patients with dementia initially present with an episode of major
depression that includes memory difficulties.
Based upon meta-analyses of neurocognitive studies that have compared patients with major
depression with healthy controls, major depression is marked by deficits in [7-9]:
Attention.
Concentration.
Cognitive flexibility (concept or set shifting).
Executive function (eg, planning, problem solving, reasoning, and impulsivity).
Information processing (psychomotor) speed.
Memory.
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Verbal fluency (listing as many words as possible from a category [eg, animals or fruits] in a set
time, typically one minute).
Social cognition (often referred to as theory of mind; the ability to infer the thoughts, intentions,
or emotions of others based upon verbal and nonverbal communication such as facial
expression, gestures, and body language).
Neurocognitive dysfunction is greater in patients who are less educated and older, and patients with
more severe depressive symptoms [7]. In addition, cognitive impairments can interfere with
occupational functioning [7] and persist after patients have remitted from major depression [8,10].
Psychomotor agitation or retardation Major depressive episodes may include psychomotor

disturbances [2]:
Agitation Excessive motor activity that is usually nonproductive, repetitious, and accompanied
by a feeling of inner tension; examples include hand-wringing, pacing, and fidgeting.
Retardation Generalized slowing of body movements, thinking, or speech. Speech volume,

quantity, and inflection may be decreased, with increased latency in answering questions.
Psychomotor disturbances are less common than other symptoms, but indicate that the patient is
more severely ill [2,11].
Feelings of worthlessness or excessive guilt The self-perceptions of depressed patients may be

marked by feelings of inadequacy, inferiority, failure, worthlessness, and inappropriate guilt [2].
Worthlessness and guilt can occur in unipolar major depression and persistent depressive disorder,
and frequently manifest with misinterpreting neutral events or minor setbacks as evidence of personal
failings.
Suicidal ideation and behavior Depressed patients can experience recurrent thoughts of death or
suicide, and may attempt suicide. Suicidal ideation may be passive, with thoughts that life is not worth
living or that others would be better off if the patient was dead. By contrast, active suicidal ideation is
marked by thoughts of wanting to die or commit suicide, and indicates the patient is severely ill. In
addition, there may be suicide plans, preparatory acts (eg, selecting a time and location to commit
suicide, purchasing a large amount of medication or a gun, or writing a suicide note), and suicide
attempts. Suicidality is increased by pervasive hopelessness (negative expectations for the future)
and the conclusion that suicide is the only option to escape ceaseless and intense emotional pain.
(See "Suicidal ideation and behavior in adults".)
Major depression with psychotic features may include auditory hallucinations telling (commanding)
patients to commit suicide. (See "Unipolar major depression with psychotic features: Epidemiology,
clinical features, assessment, and diagnosis", section on 'Psychotic features'.)
Depressed patients who intentionally commit acts of self-harm, such as superficially cutting or
burning their skin, may state that their intent was to relieve pain and that they expected the injury to
cause only mild to moderate harm [2]. Although patients may deny that they intended to kill
themselves, this behavior (nonsuicidal self-injury) indicates the patient is severely depressed;
nonsuicidal self injury is associated with suicide attempts in which patients do intend to kill
themselves [12].
Depression may be conceptualized as disturbances in:
Emotions Depressed mood and loss of interests or pleasure occur in depression. The nature of the
"depressed or dysphoric mood may vary. Some patients communicate intense sadness and
emotional distress, while others report a sense of emotional numbness ("blahs") and exhibit a
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"flattened" affect on examination. The mood may be experienced subjectively by the patient, or may
be observable on mental status examination. Patients may present with prominent anxiety or
irritability; although not specific for depression, these symptoms should be recognized as part of a
depressive episode if they occur in the context and timeframe of other depressive features.
Ideation or cognition In addition to the cognitive symptoms listed in the Diagnostic and Statistical
Manual, Fifth Edition (DSM-5) (impaired concentration or memory, worthlessness or guilt, thoughts of
death or suicide), other cognitive symptoms in depression include hopelessness, helplessness, and
ruminative thinking (defined as the tendency to dwell on a single theme, which in depression tends to
be negative).
Neurovegetative (somatic) functioning Somatic symptoms of depression include changes in sleep,

appetite or weight, energy, libido, and psychomotor activity. Some symptoms, such as loss of energy
or libido, occur in only one direction (decreased). Other symptoms, including changes in sleep,
appetite or weight, and psychomotor functioning are potentially bidirectional; insomnia and anorexia
with weight loss are most common in depression, but atypical features of hypersomnia or
hyperphagia with weight gain can occur. (See "Unipolar depression in adults: Assessment and
diagnosis", section on 'Depressive episode subtypes (specifiers)'.)
Some studies suggest that the clinical presentation of major depression may vary between females and
males, and that males may exhibit symptoms that are not included in the formal diagnostic criteria for
major depression [13,14]. Depressed women may be more likely to report neurovegetative symptoms (eg,
sleep, appetite, or energy problems) and other physical symptoms (eg, headaches, myalgias, or
gastrointestinal symptoms), as well as emotional (eg, stress or crying easily) and psychosocial symptoms
(eg, interpersonal difficulties) [15-18]. By contrast, it is hypothesized that depressed men present with
symptoms that are depressive equivalents, such as anger attacks/aggression (eg, suddenly losing
control and hurting someone or threatening to hurt someone), substance use disorders, and risk-taking
behavior (eg, casual or unsafe sex, or reckless driving) [17]. However, it is not clear that phenomena such
as substance use disorders represent a symptom of depression, or are better conceptualized as a
separate or comorbid disorder.
In addition, depressive subtypes may vary between males and females, but the differences appear to be
modest. An observational study (Sequenced Treatment Alternatives to Relieve Depression study) of 2541
outpatients with unipolar major depression found that major depression with anxious distress occurred in
more women than men (48 versus 41 percent), as did major depression with atypical features (18 versus
13 percent) [18].
CARDINAL FEATURES
Heterogeneity of depression Unipolar major depression is heterogeneous with regard to age of

onset, symptom profile, subtypes, severity, and course of illness [1,19]. As an example, two patients can
be diagnosed with major depression (table 1) without having even one symptom in common.
Continuum of severity Depression occurs along a continuum that increases in severity from
subsyndromal symptoms to the syndromes of minor depression and major depression [11,20-22]. As the
number of symptoms increases, patients report greater severity (intensity) of depression, longer
depressive episodes, and worse functioning.
A study of outpatients with either minor depression (n = 162) or major depression (n = 969) found that
across all levels of severity (low, medium, and high) for each syndrome, certain symptoms were present in
approximately 60 percent or more of patients and were thus regarded as core symptoms of depressive
syndromes [11]:
Sad, irritable, or anxious mood
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Loss of interest or pleasure

Impaired concentration and decision making
Worthlessness and inappropriate guilt
Hopelessness
Fatigue or loss of energy
By contrast, the incidence of other symptoms was lower in less severely depressed patients and
progressively increased as the level of depression severity increased, including sleep disturbance, change
in appetite or weight, somatic complaints, and psychomotor agitation. Symptoms that occurred
infrequently in minor depression but were highly prevalent in major depression included suicidal ideation
and psychomotor slowing.
SUBTYPES OF DEPRESSIVE DISORDERS Major depression and persistent depressive disorder are
heterogeneous syndromes. The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) utilizes the
following subtypes, which have been proposed in an attempt to provide greater diagnostic specificity
[1,2,23]:
Anxiety
Atypical
Catatonic
Melancholic
Mixed features
Peripartum
Psychotic
Seasonal
However, these subtypes are not mutually exclusive, meaning that the same depressive episode may
have features of more than one subtype. A study of anxious, atypical, and melancholic subtypes in
patients with unipolar major depression (n >1000) found a pure form of one subtype in 39 percent,
multiple subtypes in 36 percent, and no subtype in 25 percent [24].
The diagnosis of these subtypes is discussed separately. (See "Unipolar depression in adults:
Assessment and diagnosis", section on 'Depressive episode subtypes (specifiers)'.)
Anxious Unipolar major depression that includes high levels of anxiety symptoms is often called
anxious depression [25]. These symptoms may take the form of worrying, rumination, health anxieties,
and panic attacks. In addition, psychomotor agitation (eg, pacing and handwringing) may be considered
an anxiety equivalent. Anxiety symptoms that are part of a depressive syndrome may be difficult to
distinguish from anxiety disorders that are comorbid with depressive disorders; these comorbid disorders
are discussed separately. (See "Comorbid anxiety and depression in adults: Epidemiology, clinical
manifestations, and diagnosis".)
In several studies that defined anxious depression as an episode of unipolar major depression that
included high levels of anxiety, the anxiety component was derived from the Hamilton Rating Scale for
Depression (form 1 and form 2 and form 3), with an anxiety/somatization subscale score 7 [26,27]. The
subscale consisted of items 10 (psychic anxiety), 11 (somatic anxiety), 12 (gastrointestinal somatic
symptoms), 13 (general somatic symptoms), 15 (hypochondriasis), and 17 (insight).
Anxiety may be a prodromal or residual feature of depressive episodes; as an example, postpartum

depression often starts with increased anxiety [28]. In addition, anxiety may represent a response to
functional impairment that is caused by the depressive syndrome.
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Approximately 40 to 50 percent of major depressive episodes qualify as anxious depression [1,24,29].

Genetic, neuroimaging, and electroencephalography studies suggest that the neurobiology of anxious
depression may differ from that of non-anxious depression [30,31].
The clinical utility of diagnosing major depression with anxious features is not clear. Some studies of acute
unipolar major depression suggest that response to antidepressants is comparable in patients with or
without the anxious subtype [24,29]. However, other studies suggest that antidepressants are less
effective in patients with higher levels of baseline anxiety than patients with lower levels [26,32-34]. In
addition, adjunctive anxiolytics can improve outcomes in anxious depression [32,35]. (See "Unipolar
depression in adults: Treatment with anxiolytics".)
Atypical Atypical depression is characterized by [2]:
Reactivity to pleasurable stimuli (ie, feels better in response to positive events)

Increased appetite or weight gain
Hypersomnia
Heavy or leaden feelings in limbs
Longstanding pattern of interpersonal rejection sensitivity
According to DSM-5, the core feature of atypical major depression is mood reactivity (ie, feeling better in
response to positive events) [2]. However, this is not universally accepted, and some studies indicate that
the presence of hypersomnia or hyperphagia is sufficient for diagnosing atypical depression [1,23,36].
Historically, oversleeping and overeating were regarded as reversed or atypical symptoms of depression,
in contrast to the typical depressive symptoms of insomnia and anorexia.
Atypical depression may account for 15 to 50 percent of depressive episodes [23,24,37,38], and may be
associated with hypocortisolemia [23] and a history of trauma [39]. Compared with other types of
depression, atypical depression is associated with female gender, earlier age of onset, family history of
depression, higher rates of comorbidity (eg, anxiety disorders, substance use disorders, personality
disorders, and obesity), more depressive symptoms, greater functional impairment, and more suicide
attempts [1,36,40].
The clinical utility of diagnosing major depression with atypical features is not clear. Although several
studies of acute unipolar major depression suggest that response to antidepressants is comparable in
patients with or without the atypical subtype [24,29,37], other studies suggest that antidepressants are
less effective in patients with atypical features [38].
Catatonic Catatonic features are characterized by prominent psychomotor disturbances that occur
during most of the depressive episode. (See "Catatonia in adults: Epidemiology, clinical features,
assessment, and diagnosis" and "Catatonia: Treatment and prognosis".)
Melancholia Melancholia, which has also been labeled endogenous depression, is characterized by
[1,2,23,41]:
Disturbed affect that is unresponsive to improved circumstances

Anhedonia
Psychomotor agitation or retardation
Neurocognitive impairment
Interrupted sleep
Loss of appetite
Diurnal variation (mood and energy worse in the morning)
Melancholia is present in approximately 15 to 30 percent of major depressive episodes [24,38,42,43], and
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is more likely to be found in severely ill inpatients, including those who are psychotic [1,2,43]. The
tendency for melancholic features to repeat across recurrent episodes of major depression is only modest
[2]. Neurocognitive dysfunction may be worse in melancholic major depression than nonmelancholic
major depression [44]. Putative biological correlates of melancholia include hypercortisolemia and
disturbances in sleep architecture (eg, reduced rapid eye movement latency and deep-sleep time)
[1,23,41].
The treatment implications of melancholia are not clear. Some studies of unipolar major depression
suggest that response to acute treatment with antidepressants is comparable in patients with or without
the melancholic subtype [24,42,43]. Other studies suggest that antidepressants are less effective in
patients with melancholic features than patients without melancholic features [29,38], and yet other
studies have found that melancholia was associated with higher rates of remission [45]. Nevertheless,
melancholia generally requires pharmacotherapy or electroconvulsive therapy because of its poor
response to placebos and psychotherapies; melancholia may respond better to tricyclic antidepressants
and electroconvulsive therapy than to selective serotonin reuptake inhibitors [1,23,41].
Mixed features In DSM-5, episodes of unipolar major depression (table 1) and persistent depressive
disorder (dysthymia) (table 2) can each be accompanied by symptoms of the opposite polarity [2].
Unipolar major depression with mixed features is an episode that meets full criteria for major depression
and includes at least three of the following manic/hypomanic symptoms:
Elevated or expansive mood

Grandiosity
More talkative than usual
Flight of ideas or racing thoughts
Increased energy or goal-directed activity
Decreased need for sleep
Excessive involvement in pleasurable activities that have a high potential for painful consequences
Likewise, persistent depressive disorder with mixed features is an episode that meets full criteria for
persistent depressive disorder and includes at least three of the manic/hypomanic symptoms. Some
studies have also included irritable mood and psychomotor agitation as symptoms of mixed features
[46,47].
Depressive disorders with mixed features represent a change from the previous edition of the Diagnostic
and Statistical Manual (Fourth Edition, Text Revision; DSM-IV-TR) [48]. In DSM-IV-TR, mixed episodes
were defined more narrowly, as periods lasting at least one week, during which full criteria were met for
both a manic episode and a major depressive episode; these mixed episodes were classified as bipolar I
mood episodes.
Major depression with mixed features appears to be common [49,50]. Prospective observational studies
have found that among individuals with major depression (n = 488 and 573), subthreshold hypomania was
present in approximately 25 to 40 percent [46,51]. Comorbidity (eg, panic disorder and substance use
disorders) and a family history of mania were more common in major depression with subthreshold
hypomania, compared with major depression without hypomanic symptoms [46]. In addition, subthreshold
hypomania was associated with eventually suffering an episode of mania or hypomania, and thus
changing diagnosis from unipolar major depression to bipolar disorder.
Peripartum Peripartum depression refers to unipolar major depression or persistent depressive

disorder (dysthymia) that begins during pregnancy or within four weeks of childbirth [1,2,23]. (See
"Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and
diagnosis" and "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and
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diagnosis".)
Psychotic Episodes of major depression and persistent depressive disorder (dysthymia) may include
psychotic features such as delusions and hallucinations [1,2,23]. (See "Unipolar major depression with
psychotic features: Epidemiology, clinical features, assessment, and diagnosis".)
Seasonal Seasonal affective disorder refers to recurrent mood episodes that regularly begin during a
particular season (eg, winter) and remit during another season (eg, summer) [1,2,23]. (See "Seasonal
affective disorder: Epidemiology, clinical features, assessment, and diagnosis".)
COMORBIDITY Unipolar major depression may exist as a sole diagnosis, but is usually concurrent
with other psychiatric or general medical disorders. Many psychiatric disorders increase the risk of
developing major depression, and nearly all chronic and disabling general medical conditions do so as
well [2].
Psychiatric Unipolar major depression in clinical settings is typically marked by comorbid

psychopathology. A study of outpatients with major depression (n = 810) found that comorbidity was
present in 69 percent, and that the mean number of comorbid psychiatric diagnoses was 1.4 [52]. In
addition, a nationally representative survey in the United States found that among individuals who
suffered a major depressive episode in the prior 12 months, at least one comorbid disorder was present in
76 percent [53]. The following disorders occurred more often in the depressed individuals than the general
population:
Anxiety disorders
Agoraphobia without panic disorder

Generalized anxiety disorder
Panic disorder
Separation anxiety disorder
Social anxiety disorder
Specific phobia
Posttraumatic stress disorder
Obsessive-compulsive disorder
Attention deficit hyperactivity disorder
Oppositional defiant disorder
Intermittent explosive disorder
Substance (alcohol and drug) use disorders
Comorbidity is also common among patients with persistent depressive disorder [54].
Multiple comorbid psychiatric disorders can occur simultaneously in patients with major depression.
Nationally representative surveys in 10 developed countries found that among individuals with major
depression in the prior 12 months, three or more comorbid disorders were present in 19 percent [55].
Among patients with major depression and co-occurring psychiatric disorders, the onset of major
depression generally follows onset of the other disorder. As an example, a nationally representative
survey in the United States found that among individuals with major depression and comorbidity (eg,
anxiety disorders and substance use disorders), the onset of depression followed onset of the co-
occurring disorder in nearly 90 percent [56]. A separate study found the same temporal sequence for
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patients with co-occurring persistent depressive disorder (dysthymia) and anxiety disorders, such that the
anxiety disorders usually preceded onset of dysthymia [54].
The symptom of anxiety (anxious mood) is a common manifestation of depressive disorders, and is
distinguished from anxiety disorders. Anxiety that is only present during periods of active depression and
does not meet full diagnostic criteria for a specific anxiety disorder does not warrant a separate diagnosis.
The prognosis for depression with any comorbidity is poorer than for depression occurring in isolation
[54,57,58].
Personality disorders Personality disorders are common in outpatients and inpatients with
depressive disorders [59]:
A meta-analysis (83 studies) found that in 17,265 patients with unipolar major depression, at least
one personality disorder was present in 45 percent.
A meta-analysis (21 studies) found that in 11,941 patients with persistent depressive disorder
(dysthymia), at least one personality disorder was present in 60 percent.
The most common personality disorders in both depressive disorders were avoidant, borderline,
dependent, and obsessive-compulsive.
Concerns have been raised about the validity of diagnosing personality disorders during active episodes
of major depression, and whether personality disturbances that are identified in the context of a
depressive episode represent enduring traits rather than transient state phenomena. However,
prospective observational studies indicate that personality pathology diagnosed during major depressive
episodes persists after the depressive episodes remit [58,60]. Additional information about diagnosing
personality disorders is discussed separately. (See "Overview of personality disorders", section on
'Diagnosis'.)
General medical Depression and comorbid general medical illnesses often occur together, and
individuals with depression are at increased risk of subsequently developing general medical illnesses,
compared with nondepressed individuals [61-63]. Nationally representative surveys of depressed
individuals (n >50,000) [55] and studies of depressed primary care patients (n >140,000) [64] both
suggest that among depressed people, at least one general medical condition is present in approximately
70 percent. In addition, multiple comorbidities are often observed [64]. The nationally representative
surveys found that among individuals with major depression, three or more conditions are present in 28
percent [55].
The relationship between depression and comorbid general medical illnesses is bidirectional in some
instances but not in others. As an example, a meta-analysis of 15 prospective observational studies (n
>62,000 patients) found that depression at baseline increased the risk of subsequently becoming obese
(odds ratio 1.6), and that obesity at baseline increased the risk of depression at follow-up (odds ratio 1.6)
[65]. By contrast, a meta-analysis of six prospective studies (n >83,000 patients) found that depression at
baseline was associated with subsequent onset of asthma (relative risk 1.4), whereas a meta-analysis of
two prospective studies (n >25,000 patients) found that asthma at baseline was not associated with
subsequent onset of depression [66].
The depression-general medical comorbidity interface is not specific to any disease type or organ system
[67,68]. In nationally representative surveys in developed countries, many general medical disorders
occurred more often in depressed individuals than the general population [55]. Among individuals with
major depression in the prior 12 months, the prevalence of specific general medical comorbidities was
follows:
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Cancer 4 percent of depressed patients

Cardiovascular (eg, hypertension, myocardial infarction, and stroke) 20 percent
Diabetes 5 percent
Musculoskeletal (eg, arthritis) 41 percent
Respiratory (eg, seasonal allergies, asthma, and chronic obstructive pulmonary disease) 33 percent
Ulcer 4 percent
A study of depressed primary care patients (n >140,000) and control patients without depression (n
>1,280,000) found that depressed patients were more likely to have each of the 32 comorbid conditions
that were assessed, including asthma, cancer, chronic kidney disease, coronary heart disease, diabetes,
epilepsy, heart failure, hypertension, inflammatory arthritis, multiple sclerosis, pain, Parkinson disease,
thyroid disorders, and viral hepatitis [64].
Major depression is also associated with an increased risk of the metabolic syndrome. A meta-analysis of
18 observational studies (n >5500 patients with interview defined unipolar major depression) estimated
that the metabolic syndrome was present in 30 percent [69]. The prevalence of the metabolic syndrome
was greater in depressed patients than age and sex matched control subjects (odds ratio 1.5).
In addition, the prognosis of depression is worsened by the presence of significant general medical
comorbidity. Nevertheless, in the context of severe physical disease and disability, the potential efficacy of
depression treatments, with resulting improvements in self-rated health and functional status, should be
conveyed to patients and families. (See "Unipolar depression in adult primary care patients and general
medical illness: Evidence for the efficacy of initial treatments", section on 'Depression in general medical
illness'.)
Most major, chronic general medical disorders, as well as many subacute and acute medical conditions
and their treatments, increase the risk of subsequent depression [67]. The incidence of depression may
be particularly high in central nervous system diseases (eg, Parkinson disease, stroke, and traumatic
brain injury) [70-73], cardiovascular disorders [74,75], cancer [76], and conditions involving immune and
inflammatory mechanisms (eg, systemic lupus erythematosus [77]).
In addition, depression worsens the outcome of comorbid physical conditions, including the risk of death
[63]. As an example, comorbid depression in older patients with diabetes increased the risk for all-cause
mortality by 36 to 38 percent over a two-year period [78]. Increased mortality may be due to decreased
adherence to treatment recommendations [79] or possibly to direct effects of the depressed state on
autonomic tone, platelet aggregation, or immune and inflammatory responses [80].
Diagnosing major depression in the context of general medical disorders is discussed elsewhere. (See
"Unipolar depression in adults: Assessment and diagnosis", section on 'General medical illness'.)
In addition, separate topics discuss the clinical features and treatment of depression that occurs in the
context of cancer, end-stage renal disease, infection with the human immunodeficiency virus, myocardial
infarction, sudden cardiac arrest, stroke, organ transplantation, rheumatic disease, and systemic lupus
erythematosus, as well as patients treated with interferon alfa plus ribavirin for hepatitis C and melanoma.
COURSE OF ILLNESS The course of illness in depressive disorders is discussed separately. (See
"Unipolar depression in adults: Course of illness".)
FUNCTIONAL IMPAIRMENT Unipolar major depression was the second leading cause of disability in
the world in 2010 and persistent depressive disorder (dysthymia) was the 19th leading cause [81].
Similarly, in the United States, major depression was the second leading cause of disability and dysthymia
was the 20th [82]. Functional limitations associated with major depression in the United States are
comparable to or greater than the limitations associated with arthritis, cardiovascular disease, diabetes,
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and stroke [83].
Of the disability that was attributable to all mental and substance use disorders throughout the world in
2010, depressive disorders accounted for over 40 percent [84]. The burden of depressive disorders may
be due in part to discrimination arising from stigma [85].
Psychosocial functioning in major depression is inversely proportionate to symptom severity [86], and
most episodes are associated with poor psychosocial and physical functioning and poor self-rated health
[56,87-89]. As an example, a nationally representative survey in the United States found that psychosocial
functioning (work, household duties, relationships, and social roles) was severely or very severely
impaired in almost 60 percent of individuals with major depression [56]. Patients with severe depression
may become bed-bound and fail to perform basic activities of living including personal hygiene, toileting,
and feeding.
The relationship between course of illness in patients with depression and functional impairment is
discussed separately. (See "Unipolar depression in adults: Course of illness", section on 'Functioning'.)
Quality of life Prospective studies have found that major depression is associated with reductions in
quality of life, which refers to subjective satisfaction with ones physical, psychological, and social
functioning (eg, satisfaction with work and relationships) [90]. The relationship between course of illness in
patients with depression and quality of life is discussed separately. (See "Unipolar depression in adults:
Course of illness", section on 'Quality of life'.)
ECONOMIC COSTS Unipolar major depression is associated with economic burdens, including costs
related to medical services, medications, loss of work, and suicide. The estimated costs in the United
States in 2010 was 80 billion dollars [91].
SUICIDE Many depressed patients kill themselves, and many more attempt to do so or otherwise inflict
intentional self-injuries. (See "Unipolar depression in adults: Course of illness", section on 'Suicide' and
"Suicidal ideation and behavior in adults", section on 'Psychiatric disorders'.)
VIOLENCE Patients with depressive disorders may be more likely to perpetrate violence than the
general population. In a national registry study with a mean follow-up of about three years, analyses that
controlled for potential confounding factors (eg, age, sex, and comorbid substance use or personality
disorders) found that individuals diagnosed with depression were subsequently more likely to be convicted
for violent crimes (eg, assault, robbery, or rape) compared with controls (odds ratio 2.6) [92]. The absolute
risk of violent offending in men with and without depression was 3.7 and 1.2 percent, and among women
with and without depression was 0.5 and 0.2 percent. However, it is not clear whether depressions
association with violence is independent of clinically important unmeasured factors, such as personality
trait vulnerabilities not captured in registry diagnoses of personality disorders.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The
Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who prefer short,
easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on patient info and the keyword(s) of interest.)
Basics topics (see "Patient education: Depression (The Basics)")
11 de 25 05/12/2017 17:03
Beyond the Basics topics (see "Patient education: Depression in adults (Beyond the Basics)" and
"Patient education: Depression in children and adolescents (Beyond the Basics)")
SUMMARY
Depression can refer to a mood state, syndrome, or specific mental disorder. (See 'Definitions of
depression' above.)
Depressive symptoms include depressed mood, loss of interest or pleasure, decreased appetite and
weight or increased appetite and weight, insomnia or hypersomnia, fatigue, cognitive dysfunction,
psychomotor agitation or retardation, feelings of worthlessness or guilt, and suicidal ideation and
behavior. (See 'Symptoms' above.)
Unipolar major depression is heterogeneous with regard to age of onset, symptom profile, subtypes,
severity, and course of illness. (See 'Heterogeneity of depression' above.)
Subtypes of depressive episodes include anxious, atypical, catatonia, melancholia, mixed features,
peripartum, psychotic, and seasonal. (See 'Subtypes of depressive disorders' above.)
Patients with unipolar major depression typically suffer comorbid psychiatric disorders, including
anxiety disorders (agoraphobia without panic disorder, generalized anxiety disorder, panic disorder,
separation anxiety disorder, social anxiety disorder, and specific phobia), posttraumatic stress
disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, oppositional defiant
disorder, intermittent explosive disorder, and substance use disorders. Comorbid personality
disorders are also common, especially avoidant, borderline, dependent, and obsessive-compulsive.
(See 'Psychiatric' above.)
Depression and comorbid general medical illnesses often occur together, and the relationship is
bidirectional (depressed patients usually have at least one general medical condition, and patients
with general medical disorders are often at increased risk of depression). General medical
comorbidity is not specific to any disease type or organ system. (See 'General medical' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 91774 Version 14.0
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GRAPHICS
DSM-5 diagnostic criteria for a major depressive episode
A. Five (or more) of the following symptoms have been present during the same two-week period and represent
a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
NOTE: Do not include symptoms that are clearly attributable to another medical condition.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad,
empty, hopeless) or observations made by others (eg, appears tearful). (NOTE: In children and adolescents,
can be irritable mood.)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
(as indicated by either subjective account or observation)
3) Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a
month), or decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make
expected weight gain.)
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
(not merely self-reproach or guilt about being sick)
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by their subjective
account or as observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or
a suicide attempt or a specific plan for committing suicide
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another medical
condition.
NOTE: Criteria A through C represent a major depressive episode.
NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a serious
medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia,
poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such
symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive
episode in addition to the normal response to a significant loss should also be carefully considered. This decision
inevitably requires the exercise of clinical judgement based on the individual's history and the cultural norms for
the expression of distress in the context of loss.
D. The occurence of the major depressive episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia
spectrum and other psychotic disorders.
E. There has never been a manic or hypomanic episode.
NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like epsidoes are substance-
induced or are attributable to the physiological effects of another medical condition.
Specify:
With anxious distress
With mixed features
With melancholic features
With atypical features
With psychotic features
With catatonia
18 de 25 05/12/2017 17:03
With peripartum onset
With seasonal pattern
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright
2013). American Psychiatric Association. All Rights Reserved.
Graphic 89994 Version 11.0
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Hamilton Rating Scale for Depression, page 1
Hamilton, M. A rating scale for depression. J Neurosurg Psychiatry 1960; 23:56.
20 de 25 05/12/2017 17:03
21 de 25 05/12/2017 17:03
22 de 25 05/12/2017 17:03
DSM-5 diagnostic criteria for persistent depressive disorder (dysthymia)
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or
observation by others, for at least two years.
NOTE: In children and adolescents, mood can be irritable and duration must be at least one year.
B. Presence, while depressed, of two (or more) of the following:
1) Poor appetite or overeating.
2) Insomnia or hypersomnia.
3) Low energy or fatigue.
4) Low self-esteem.
5) Poor concentration or difficulty making decisions.
6) Feelings of hopelessness.
C. During the two-year period (one year for children or adolescents) of the disturbance, the individual has never
been without the symptoms in Criteria A and B for more than two months at a time.
D. Criteria for a major depressive disorder may be continuously present for two years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for
cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional
disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a
medication) or another medical condition (eg, hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
NOTE: Because the criteria for a major depressive episode include four symptoms that are absent from the
symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have
depressive symptoms that have persisted longer than two years but will not meet criteria for persistent
depressive disorder. If full criteria for a major depressive episode have been met at some point during the
current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis
of other specified depressive disorder or unspecified depressive disorder is warranted.
Specify if:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With peripartum onset
Specify if:
In partial remission
In full remission
Specify if:
Early onset: If onset is before 21 years.
Late onset: If onset is at age 21 years or older.
Specify if (for most recent two years of persistant depressive disorder):
With pure dysthymic syndrome: Full criteria for a major depressive episode have not been met in at least
the preceding two years.
With persistent major depressive episode: Full criteria for a major depressive episode have been met
throughout the preceding two-year period.
23 de 25 05/12/2017 17:03
With intermittent major depressive episodes, with current episode: Full criteria for a major
depressive episode are currently met, but there have been periods of at least eight weeks in at least the
preceding two years with symptoms below the threshold for a full major depressive episode.
With intermittent major depressive episodes, without current episode: Full criteria for a major
depressive episode are not currently met, but there has been one or more major depressive episodes in at
least the preceding two years.
Specify current severity:
Mild
Moderate
Severe
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright
2013). American Psychiatric Association. All Rights Reserved.
24 de 25 05/12/2017 17:03
Contributor Disclosures
Jeffrey M Lyness, MD Nothing to disclose Peter P Roy-Byrne, MD Employment: Mass Medical Society
(journal Watch); Wiley Lliss (Depression and Anxiety) [Editor in Chief]. Stock Options: Valant Medical
Solutions [behavioral health (EMR)]. David Solomon, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy
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Depressão Unipolar - Fatores Clínicos - UpToDate 2017

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Unipolar depression in adults: Clinical features - UpToDate https://www.uptodate.com/contents/unipolar-depression-in-adults-clini...

Official reprint from UpToDate

Unipolar depression in adults: Clinical features

Author: Jeffrey M Lyness, MD

(See "Unipolar depression in adults: Assessment and diagnosis".)

DEFINITIONS OF DEPRESSION It is important to recognize the potential for confusion engendered by

Mood state, which may be normal or part of a psychopathological syndrome

As an example, major depression is a syndrome that occurs as a consequence of several disorders,

Depressed mood Depressed mood (dysphoria) is an essential feature of unipolar major

Loss of interest or pleasure Loss of interest or pleasure (anhedonia) in formerly pleasurable

Initial insomnia Difficulty getting to sleep

Neurocognitive dysfunction Unipolar major depression, persistent depressive disorder, and

Cognitive flexibility (concept or set shifting).

Executive function (eg, planning, problem solving, reasoning, and impulsivity).

Information processing (psychomotor) speed.

Psychomotor agitation or retardation Major depressive episodes may include psychomotor

Retardation Generalized slowing of body movements, thinking, or speech. Speech volume,

Feelings of worthlessness or excessive guilt The self-perceptions of depressed patients may be

Depression may be conceptualized as disturbances in:

Neurovegetative (somatic) functioning Somatic symptoms of depression include changes in sleep,

Heterogeneity of depression Unipolar major depression is heterogeneous with regard to age of

Sad, irritable, or anxious mood

Loss of interest or pleasure

Anxiety may be a prodromal or residual feature of depressive episodes; as an example, postpartum

Approximately 40 to 50 percent of major depressive episodes qualify as anxious depression [1,24,29].

Atypical Atypical depression is characterized by [2]:

Reactivity to pleasurable stimuli (ie, feels better in response to positive events)

Disturbed affect that is unresponsive to improved circumstances

Melancholia is present in approximately 15 to 30 percent of major depressive episodes [24,38,42,43], and

Elevated or expansive mood

Peripartum Peripartum depression refers to unipolar major depression or persistent depressive

Psychiatric Unipolar major depression in clinical settings is typically marked by comorbid

Agoraphobia without panic disorder

Posttraumatic stress disorder

Attention deficit hyperactivity disorder

Oppositional defiant disorder

Intermittent explosive disorder

Substance (alcohol and drug) use disorders

Cancer 4 percent of depressed patients

and stroke [83].

Basics topics (see "Patient education: Depression (The Basics)")

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Affect Disord 2014; 152-154:19.

care. Am J Med 2008; 121:S1.

Topic 91774 Version 14.0

DSM-5 diagnostic criteria for a major depressive episode

4) Insomnia or hypersomnia nearly every day

6) Fatigue or loss of energy nearly every day

NOTE: Criteria A through C represent a major depressive episode.

E. There has never been a manic or hypomanic episode.

With anxious distress

With mixed features

With melancholic features

With atypical features

With psychotic features

With peripartum onset

With seasonal pattern

Graphic 89994 Version 11.0

Hamilton Rating Scale for Depression, page 1

Hamilton, M. A rating scale for depression. J Neurosurg Psychiatry 1960; 23:56.

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Hamilton Rating Scale for Depression, page 2

Hamilton, M. A rating scale for depression. J Neurosurg Psychiatry 1960; 23:56.

Graphic 60363 Version 2.0