Types of Depression

The types of depression can be viewed on a continuum according to the severity of the illness. Differences occur in the severity of depressive symptomatology, including transient, mild, moderate, and severe (Townsend, 2008). There are two main classification systems for depression based on the

International Classification of Diseases, 10th revision (ICD-10) (World Health

Organization, 1993), and the Diagnostic and Statistical Manual, 4th edition,

known as DSM-IV-TR (American Psychiatric Association, 2000). Both ICD- 10 and DSM-IV-TR classify depressive episodes on the basis of severity and whether psychotic features are present. In DSM-IV-TR, an episode of major depression with appropriate clinical symptomatology can be specified as atypical depression, whereas in ICD-10 atypical depression is classified separately under ‘Other depressive episodes’. Both ICD-10 and DSM-IV recognise the diagnosis of recurrent brief depression, but under slightly different headings.

In Thailand, all psychiatric hospitals run by the Department of Mental Health, Ministry of Public Health, use ICD-10 for classifying mental illnesses. Thus, the following types of depression are based on the ICD-10 classification for depressive disorders.

According to ICD-10 (World Health Organization, 1993, pp.82-83), the criteria for a mild depressive episode (F32.0) are as follows: criterion A, the general criteria for depressive episode (F32) have been met, including the episode should last for at least two weeks, there have been no hypomanic or manic episodes (F30) at any time in the individual’s life, and the episode is not attributable to psychoactive substance use (F10–F19) or to any organic mental disorder (F00–F09); criterion B, at least two of the following three symptoms must be present: 1) depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, sustained for at least two weeks; 2) loss of interest or pleasure in activities that are normally pleasurable; 3) decreased energy or increased fatigability; criterion C, an additional symptom or symptoms should be present to give a total of at least four from the total list including 1) loss of confidence or self-esteem; 2) unreasonable feelings and inappropriate guilt; 3) recurrent thoughts or behaviour of suicide; 4) evidence of diminished ability to think or concentrate; 5) change of psychomotor activity, with agitation or retardation; 6) sleep disturbance of any type; 7) change in appetite with corresponding weight change.

Generally, in mild depression, alterations occur in four spheres of human functioning: (1) affective: denial of feelings, anger, guilt, sadness, and

hopelessness; (2) behaviour: tearfulness, restlessness, withdrawal, and

agitation; (3) cognitive: preoccupation with loss, self-blame, and ambivalence;

and (4) physiological: anorexia or overeating, insomnia or hypersomnia, chest

2.2.6.2 Moderate depression

In this thesis, participants who met the inclusion criteria for moderate depression were recruited to take part in the study. According to ICD-10 (World Health Organization, 1993, p.83 ), the criteria for a moderate depressive episode (F32.1) are as follows: criterion A, the general criteria for depressive episode (F32) must be met (as stated above for a mild depressive episode [F32.0]); criterion B, at least two of the three symptoms from criterion B of F32.0 must be present; criterion C, additional symptoms from criterion C of F32.0 must be present, to give a total of at least six symptoms.

Overall, symptoms of moderate depression can be described as alterations in four spheres of human functioning (Townsend, 2008): (1) affective: feelings of

sadness, helplessness, hopelessness, low self-esteem, and difficulty experiencing pleasure in activities; (2) behaviour: psychomotor retardation,

slowed speech, limited verbalisation, social isolation, self-destructive behaviour is possible, and decreased interest in personal hygiene and grooming; (3) cognitive: retarded thinking processes, repetitive thoughts,

generally portraying pessimism and negativism, and behaviour reflecting suicide ideation is possible; and (4) physiological: anorexia or overeating, sleep

disturbances, amenorrhoea, decreased libido, headaches, backaches, chest pain, abdominal pain, and fatigue.

According to ICD-10 (World Health Organization, 1993, p.84 ), the criteria for a severe depressive episode, without psychotic symptoms (F32.2) are as follows: criterion A, the general criteria for depressive episode (F32) must be met (as stated above for mild depressive episode [F32.0]); criterion B, at least two of the three symptoms from criterion B of F32.0 must be present; criterion C, additional symptoms from criterion C of F32.0 must be present, to give a total of at least eight symptoms.

Generally, the symptoms of severe depression can be described as alterations in four spheres of human functioning: (1) affective: feelings of total despair,

hopelessness and worthlessness, prevalent feelings of emptiness, loneliness and

inability to experience pleasure in activities; (2) behaviour: severe

psychomotor retardation, purposeless movement, slumped posture, virtually nonexistent communication, social isolation, poor personal hygiene and grooming; (3) cognitive: delusional thinking, with persecutory and somatic

delusions, inability to concentrate, hallucinations, self-blame, and thoughts of suicide; and (4) physiological: a general slowdown of the entire body, reflected

in sluggish digestion, constipation, urinary retention, amenorrhoea, diminished libido, weight loss, and difficulty falling sleep (Townsend, 2008). Furthermore, approximately 80% of people with severe depression complain of trouble in sleeping, especially early-morning awakening and multiple awakenings at night, during which they ruminate about their problems. Many have decreased appetite and weight loss, but others experience increased appetite and weight gain and sleep longer than usual (Sadock & Sadock, 2004).

2.2.7 Onset and Prognosis of Depression