The stages from decreased positive well being through mild depression to major depression without psychotic features from William Styron Darkness Visible6

• The shadows of nightfall seemed more sober, my mornings were less buoyant, walks in the woods became less zestful, and there was a moment during my working hours when a kind of panic and anxiety overtook me, just for a few minutes, accompanied by a visceral queasiness ...

• ... As the disorder gradually took full possession of my system, I began to conceive that my mind itself was like one of those outmoded small-town telephone exchanges, being gradually inundated by flood-waters ...

• ... I particularly remember the lamentable near disappearance of my voice ... The libido also made an early exit, like everything else within the scope of sensation, was utterly without savour ...

• ... My few hours of sleep were usually terminated at three or four in the morning, when I stared up into yawning darkness... I'm fairly certain that it was during one of these insomnia trances that there came over me the knowledge that this condition would cost me my life, if it continued on such a course ... I had not conceived precisely how my end would come. In short, I was still keeping the idea of suicide at bay ... What I had begun to discover is that the gray drizzle of horror, induced by depression, takes on the quality of physical pain ...

Psychomotor retardation is more common in younger depressed patients; psychomotor agitation is more common in elderly patients. Psychomotor retardation is manifested not only in decreased motor activity (e.g. fixed facial expression, reduced gestures, and slow movements) but also in decreased verbal activity, concentration difficulties, and emotional withdrawal. Psychomotor agitation can range from hand-wringing and restlessness to almost continuous pacing.

Both in DSM-IV and ICD-10, major depressive states can be further specified as a melancholic or somatic syndrome. In earlier descriptions (including Freud's 'Mourning and melancholia'^.1)), endogenous or somatic depression is distinguished from psychogenic or reactive depression by 'early morning awakening' and 'depression regularly worse in the morning'. These two signs are the only features of somatic or melancholic depression not included in the list of symptoms in Table... 1. Strictly speaking, diurnal variation in symptoms is not itself a symptom but rather a description of their course. The most 'somatic' symptom in Table.! is change in body weight (Styron had lost 20 to 25 pounds over a period of 6 weeks, when the illness developed into a major depression). (1.2>

Styron's depression (Box!) included the somatic feature of early morning awakening and suicidal thoughts. The latter are not just a consequence of the other symptoms. Styron described how during depression he could still keep '...the idea of suicide at bay...'. At a later stage (not shown in Box 1), just before he was admitted to hospital, Styron tried to write a suicide letter. Suicidal thoughts were often present late at night, when anxiety symptoms had lifted. (!2)

Measurements of social behaviour and subjective state have shown that acute major depression is among the most disabling and distressing of medical disorders. (13> The constant mental pain and the suicidal symptoms seriously affect quality of life. The suicidal risk in major depression is especially high when psychomotor retardation is improving under treatment. The treating physician or the relatives typically observe improvement in the depressive symptoms before the patient does, because psychomotor retardation improves before mood state or hopelessness.

The risk is especially high in socially isolated people. Major depression has the highest risk of suicide of all mental disorders, and all patients with major depression should be assessed for the risk of suicide.

Previous editions of DSM and ICD included 'involutional melancholia', which was considered to be a distinct entity, among the late-onset types of depression. However, it is now regarded as a typical major depression.

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