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Depression — theme and variations

Depression — theme and variations

(This article was first printed in the October 2004 issue of the Harvard Mental Health Letter. For more information or to order, please go to

The American Psychiatric Association requires any five of nine symptoms for a diagnosis of major depression. As the definition implies, these symptoms do not all appear in everyone who is depressed. Two studies explore the consequences for the understanding of depression and come to contrasting conclusions. One study suggests that an individual patient’s symptoms are not consistent, but change more or less unpredictably from one episode of depression to the next. The other study suggests that there are several sets of depressive symptoms that are distinguishable genetically and therefore likely to persist in a given individual.

American researchers studying 78 hospitalized patients who had had at least 2 episodes of severe depression found that, with a few exceptions, it was impossible to predict reliably from the symptoms of one episode which symptoms would appear in the next episode. The researchers also looked for the persistence of sets of symptoms that are regarded as characteristic of specific types of depression: atypical depression (excessive sleep and eating and weight gain, feelings of worthlessness); melancholic depression (insomnia, anxiety, appetite loss, slowed movements, feeling worse in the morning); and psychotic depression (paranoia, guilt, hypochondria, hopelessness). Again, there was no consistency; for example, a patient who had psychotic symptoms in the first episode and one who had melancholic symptoms in the first episode were equally likely to show psychotic (or melancholic) symptoms in the second episode. Among these patients, there were apparently no distinct types of depression. Instead, the same underlying illness was taking different forms at different times.

European researchers found evidence to the contrary in a large international genetic study including more than 1,000 biologically related siblings with recurrent depression. From answers to standard clinical interviews, they identified five groups of symptoms that often went together, which they call “dimensions” of depression:

  • sadness, hopelessness, loss of pleasure and interest in life
  • slow movements, lethargy, loss of energy, sexual interest, and initiative
  • anxiety
  • restlessness, agitation, irritability, guilt, and suicidal tendencies
  • excessive sleep and appetite

The second, third, and fourth dimensions were more highly correlated among siblings than among unrelated persons. For example, if one sibling had mainly the low-energy symptoms, the other sibling was far more likely than average to have those symptoms as well. The authors suggest that these dimensions may help to identify genetically distinct types of depression.

Korszun A, et al. “Familiality of Symptom Dimensions in Depression,” Archives of General Psychiatry (May 2004): Vol. 61, No. 5, pp. 468–74.

Oquendo MA, et al. “Instability of Symptoms in Recurrent Major Depression: A Prospective Study,” American Journal of Psychiatry (Feb. 2004): Vol. 161, No. 2, pp. 255–61.

Understating Depression: a special report on mental health

Understanding Depression

Depression affects nearly 19 million adults each year, yet this common disease is often misunderstood or misdiagnosed. While depression can’t simply be willed away by "shaking off" your blues, there are many effective treatments that can bring joy back into your life. Reading Understanding Depression and sharing it with those closest to you might help improve your life — or the life of someone close to you!. Read more »