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Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and sense of well-being. People with depressed mood can feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, ashamed or restless. They may lose interest in activities that were once pleasurable, experience loss of appetite or overeating, have problems concentrating, remembering details or making decisions, and may contemplate, attempt or commit suicide. Insomnia, excessive sleeping, fatigue, aches, pains, digestive problems or reduced energy may also be present.

Depressed mood is a feature of some psychiatric syndromes such as major depressive disorder, but it may also be a normal reaction to life events such as bereavement, a symptom of some bodily ailments or a side effect of some drugs and medical treatments.

Life events
Adversity in childhood, such as bereavement, neglect, unequal parental treatment of siblings, physical abuse or sexual abuse, significantly increases the likelihood of experiencing depression over the life course.

Life events and changes that may precipitate depressed mood include childbirth, menopause, financial difficulties, job problems, a medical diagnosis (cancer, HIV, etc.), bullying, loss of a loved one, natural disasters, social isolation, relationship troubles, jealousy, separation, and catastrophic injury.

Adolescents may be especially prone to experiencing depressed mood following social rejection.

Medical treatments
Certain medications are known to cause depressed mood in a significant number of patients. These include interferon therapy for hepatitis C.

Non-psychiatric illnesses
Depressed mood can be the result of a number of infectious diseases, nutritional deficiencies, neurological conditions and physiological problems, including hypoandrogenism (in men), Addison's disease, Lyme disease, multiple sclerosis, chronic pain, stroke, diabetes, cancer, sleep apnea, and disturbed circadian rhythm. It is often one of the early symptoms of hypothyroidism (reduced activity of the thyroid gland).

Psychiatric syndromes
A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated mood, cognition and energy levels, but may also involve one or more episodes of depression. When the course of depressive episodes follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be described as a seasonal affective disorder.

Outside the mood disorders: borderline personality disorder often features an extremely intense depressive mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode; and posttraumatic stress disorder, an anxiety disorder that sometimes follows trauma, is commonly accompanied by depressed mood.

Substance use disorder
Depression is sometimes associated with substance use disorder. Both legal and illegal drugs can cause substance use disorder.

Assessment
Questionnaires and checklists such as the Beck Depression Inventory or the Children's Depression Inventory can be used to detect and assess the severity of depression.

DSM-F Depressive Disorders
Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder

Disruptive Mood Dysregulation Disorder
New Diagnosis to address appropriate classification and treatment of children to differentiate from Bipolar Disorder Involves chronic, severe persistent irritability Frequent temper outbursts 6 month to 1 year prevalence among children and adolescents – 2 to 5% Onset must be before 10 Cannot be applied to children before age 6 Predominantly male

Major Depressive Disorder
Occurrence of one or more major depressive episodes Most have recurrent episodes – 35- 85% of individuals The longer the period of recovery, the lower risk of relapse First year – 20% risk Second year – 40% risk Median number of episodes – 4 to 7 Absence of mania or hypomania Not just “the blues” Can’t just “shake it off” Half of those with MDD fail to seek help Latinos and African Americans less likely to receive care Family physicians often fail to detect or make referrals for depression Part of Medicare assessment now Major Depressive Disorder (continued) An untreated episode may last 6 months or longer Occurs mostly during late teenage and early adult years Women more likely to suffer from major depression Women 21%; Men 12% Average age of onset is mid-20s In extreme cases, may have delusions May be single episode or repeated 16.5% of population has suffered from Major depression 7% suffer at any given year Specifiers Mild, moderate, severe With Psychotic Features 5 to 20% Delusions Hallucinations In Partial remission In Full remission No signs or symptoms for past two months Unspecified With anxious distress With mixed features With melancholic features With mood-congruent psychotic features With mood-incongruent psychotic features With Catatonia With peripartum onset With seasonal pattern

Affects: Work and productivity Average worker loses 27.2 work days Family and marital relationships Medical conditions Driving ability Risk Factors Age – onset greatest in young adults (mean age is 30) 25% of 18 to 29-year-olds SES – lower SES more at risk Marital Status – separated or divorced at higher risk Native American individuals four times more likely than other groups Gender – Women twice as likely Why? Hormonal fluctuations Greater stress burden Coping styles – Rumination Self-esteem issues Reporting bias

Grief vs. Depression
62% have symptoms of depression after death of loved one 10 to 20% continue to grieve after a year Suicidal thoughts increase Predominant feelings of emptiness and loss versus persistent depressed mood and inability to anticipate happiness Grief tends to be associated with thoughts or reminders of deceased In grief self-esteem preserved, except for guilt around failings about deceased

Seasonal Affective Disorder (SAD)
A subcategory of a mood disorder Major Depressive Disorder with seasonal pattern 2.7% of North Americans Rates higher in northern states theories Seasonal changes affect biological rhythms or melatonin levels Melatonin levels increase in winter Excessive sleep and increased appetite Phototherapy shows improvement within several days of treatment Antidepressant medication also helpful

Peripartum Depression
80% of new mothers experience “blues” for first two weeks following birth Hormonal changes One out of seven mothers experience clinical depression. Affects 10 to 15% of U.S. women in first year after childbirth Begins within 4 weeks following birth Risk factors Women with prior history of mood disorder First-time or single mothers Those with financial problems or marital issues Lack of social support Sick or temperamentally difficult child Increases risk of future depressive episodes If severe, can cause postpartum psychosis

Persistent Depressive Disorder (Dysthymia)
Milder, but more chronic, form of depression Often begins in childhood/adolescence or early adulthood 76% of children later developed Major Depressive Disorder Risk of Major Depressive Disorder is 90% Double Depression Depressed mood for most of the day, for more days than not, for at least two years Can last 20 years; median duration is 5 years Similar symptoms as major depressive disorder but symptoms are less severe and/or intense During the 2-year period, the person has never been without the symptoms for more than 2 months at a time Rarely requires hospitalization Affects 4% of population in their lifetimes More common in women than men

Treatment
Depressed mood may not require any professional treatment, and may be a normal reaction to certain life events, a symptom of some medical conditions, or a side effect of some drugs or medical treatments. A prolonged depressed mood, especially in combination with other symptoms, may lead to a diagnosis of a psychiatric or medical condition, e.g. of a mood disorder, which may benefit from treatment. Different sub-divisions of depression have different treatment approaches.

The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor.