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Present in most depressions

  • Mood varies from mild sadness to intense despondency and feelings of guilt, worthlessness, and hopelessness.

  • Difficulty in thinking, including inability to concentrate, ruminations, and lack of decisiveness.

  • Loss of interest, with diminished involvement in work and recreation.

  • Somatic complaints such as disrupted, lessened, or excessive sleep; loss of energy; change in appetite; decreased sexual drive.

Present in some severe depressions

  • Psychomotor retardation or agitation.

  • Delusions of a somatic or persecutory nature.

  • Withdrawal from activities.

  • Physical symptoms of major severity, eg, anorexia, insomnia, reduced sexual drive, weight loss, and various somatic complaints.

  • Suicidal ideation.

Possible symptoms in mania

  • Mood ranging from euphoria to irritability.

  • Sleep disruption.

  • Hyperactivity.

  • Racing thoughts.

  • Grandiosity or extreme overconfidence.

  • Variable psychotic symptoms.


Depression is extremely common, with up to 30% of primary care patients having depressive symptoms. The COVID-19 pandemic has undoubtably increased the risk of depression. One meta-analysis of studies of community-based prevalence of depression found a seven-fold increase in depression in some heavily impacted communities in Europe and Asia. US national surveys show a three-fold increase in the prevalence of depressive symptoms, with risk factors including lower income, less than $5000 in savings, and exposure to stressors. Depression may be the final expression of (1) genetic factors (neurotransmitter dysfunction), (2) developmental problems (personality problems, childhood events), or (3) psychosocial stresses (divorce, unemployment). It frequently presents in the form of somatic complaints with negative medical workups. Although sadness and grief are normal responses to loss, depression is not.

Mania is often combined with depression and may occur alone, together with depression in a mixed episode, or in cyclic fashion with depression.


In general, there are four major types of depression, with similar symptoms in each group.

A. Adjustment Disorder with Depressed Mood

Depressed mood may occur in reaction to some identifiable stressor or adverse life situation, usually loss of a person by death (grief reaction), divorce, etc; financial reversal (crisis); or loss of an established role, such as being needed. Anger is frequently associated with the loss, and this in turn often produces a feeling of guilt. Adjustment disorder by definition occurs within 3 months of the stressor and causes significant impairment in social or occupational functioning. The symptoms range from mild sadness, anxiety, irritability, worry, and lack of concentration, discouragement, and somatic complaints to the more severe symptoms of frank depression. When the full criteria for major depressive disorder are present, however, then that diagnosis should be made and treatment instituted even when there is a known stressor. The presence of a stressor is not the determining diagnostic driver; it is the resultant syndromal complex. One should not neglect treatment for major depression simply because it may appear to be an understandable reaction to a particular stress or difficulty.

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