Box 51 Symptoms of depression

Core symptoms of depression Depressed mood Loss of interest and enjoyment

Reduced energy leading to increased fatiguability and diminished activity

Common symptoms of depression Reduced concentration and attention Reduced self-esteem and self-confidence Ideas of guilt and unworthiness Bleak and pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep Diminished appetite

Fitzpatrick and Hopkins6 assessed a series of patients referred to a neurologist with headaches not due to structural disease and found that 37% had an affective disorder of at least mild severity. The preoccupation with pain may dominate the clinical picture to such an extent that the patient does not appear depressed and does not readily admit to feeling depressed. This has been described in relation to facial pain;7 the cognitive features of depression such as self reproach, suicidal thinking, and psychomotor retardation were uncommon but, in addition to pain, the patients complained of insomnia, fatigue, irritability, and agitation.

Depression also complicates existing neurological disease. In some cases, for example spinal cord injuries,8 depression appears to result largely from the personal and social implications of the neurological disability. In diseases in which there is cerebral involvement, the aetiology of depression is more complex. The mood disturbance may be triggered by the emotional impact of the disease but may also result from structural pathology, possibly through interference with neurotransmitter pathways within the brain. Depressive disorders with cerebral involvement are classified as the organic mood disorders by ICD-10.9 One of the most significant features of these disorders is that the mood disturbance, either depression or mania, may be the first manifestation of underlying neurological pathology.10 Suspicion of unrecognised physical illness should be particularly high if there is no clear psychosocial precipitant, if the mood disorder first presents in middle or late life, and if there is no family or personal disposition to psychiatric illness.11

Depression has been described as a presenting feature of cerebral tumours,12 multiple sclerosis,13,14 Parkinson's disease,15,16 and Huntington's disease17,18 but most attention has been given to its association with cerebrovascular disease. Eastwood et al.19 reported that 10% of patients in a stroke rehabilitation inpatient unit had a major depressive disorder, whereas 40% had symptoms of minor depression. Robinson et al.20 studied patients admitted to hospital after an acute stroke and found that 27% demonstrated symptoms of major depression, whereas 20% had symptoms of minor depression. The association between mood disturbance and severity of physical impairment is not a strong one and it has been proposed that the site of the vascular lesion is an important factor in determining poststroke depression. Left-sided lesions in the frontal lobe or basal ganglia have been particularly implicated.21 A recent systematic review offered no support for the hypothesis that the risk of depression after stroke is affected by the location of the brain lesion.22 In addition, other reports have found a lower prevalence of depressive illness, especially when the survey has included patients not admitted to hospital.23

Some patients with cerebrovascular disease experience mood disturbances that are too brief to justify the diagnosis of a depressive illness.24 This phenomenon, known as pathological emotionalism, is manifest by rapid changes of mood, sudden episodes of crying, and inappropriate and uncontrollable laughter. This type of mood change has been observed more commonly in patients with lesions in the left frontal and temporal areas.

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