BMN Blog

DEC 05
Depression: It’s Not Just Emotional

Dr. Sunshine arrives in her clinic at 8 am. Her lobby is full of patients. Mrs. Jane, a 45-year-old widower who has been Dr. Sunshine’s patient for 10 years. Mrs. Jane has recently been complaining about reoccurring back pain, the inability to fall asleep, and indigestion problems. Dr. Sunshine is aware of the sudden passing of Mrs. Jane’s husband a year ago and treats her physical symptoms as they present themselves with analgesics, sedatives and reflux medicine. Yet, Mrs. Jane’s complaints remain. Although compliant with her medications, Mrs. Jane’s symptoms are a result of Major Depressive Disorder. 

Sadness, melancholy, having the blues, lack of motivation, and decreased enjoyment of life are the commonly first symptoms one often looks for when diagnosing depression. While these characteristics are accurate descriptors, depression is a much more complex condition. Symptoms of the disorder can vary widely, both emotionally and physically. Differential diagnoses can range from Major Depressive Disorder to Bipolar Depressive Disorder and even Seasonal Affective Disorder. While the aforementioned disorders have the same criteria of a depressive episode, it is the duration of an episode that differentiates and determines the specific diagnosis. 

Identification of depression often relies on self-reported emotional feelings described by the patient such as sadness, crying spells, and/or lack of motivation to do daily tasks. The table below describes some of the emotional and physical depression symptoms that often show up in a health care clinic.

Symptoms Of Depression

Emotional Symptoms

  • Sadness
  • Loss of interest or pleasure in activities
  • Overwhelming feelings of loneliness, worthlessness, and hopelessness
  • Inexplicable crying spells
  • Loss of sexual desire
  • Excessive or inappropriate guilt

Physical Symptoms

  • Headaches
  • Sleep Disturbances
  • Fatigue, lack of energy
  • Back Pain
  • Significant change in appetite, resulting in weight gain or loss
  • Stomach Aches, indigestion

In health care settings, physical symptoms are often the primary complaint expressed by depressed patients. However, how often are these physical symptoms (mentioned in the above table) treated individually instead of making the link to depression? A good tip for physicians and healthcare professionals in this circumstance is to directly assess the patient’s emotional well-being based on a recurring pattern of physical symptoms as they present themselves. Useful screening tools available for physicians and healthcare professionals are the Beck Depression Inventory (BDI) and the Patient Health Questionnaire-9 (PHQ-9). The questions in these screening tools are focused around the criteria of a depressive episode as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

Examples of secondary questions to ask patients who are experiencing these reoccurring physical symptoms which could be linked to an emotional disorder include:

Over the last 2 weeks how often have you been bothered by any of the following:

  • Little interest or loss of pleasure in things?
  • Feeling down or depressed?
  • Feeling bad about yourself, or that you’re a failure, let down to your family?
  • Increased agitation?
  • Decreased ability to concentrate?

Although depression and sadness have similar features, there is an important distinction. Sadness is the emotion felt as a result of an event and typically lasts a couple days. Depression lasts longer (at least 2 weeks) and sometimes is triggered for no apparent reason. A patient with Major Depressive Disorder (MDD) feels a profound sense of hopelessness and despair. MDD can be present at any age; however, the likelihood of onset is after puberty.  Multiple depressive episodes are required to constitute MDD. 

According to the DSM-V, five or more of the following criteria have to be present during the same 2 weeks and represent a change from previous day to day functioning in order to diagnose a depressive episode:

  • Depressed mood most of the day, nearly everyday
  • Markedly diminished interest or pleasure in all or almost all activities
  • Significant weight loss (not due to diet) or weight gain
  • Insomnia or hyposomnia nearly everyday
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy nearly everyday
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate or indecisiveness
  • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan for committing suicide.


Bipolar I Disorder differs from MDD in that there are two distinct moods present in which patients alternate back and forth over time. These moods are a manic episode (abnormally elevated mood) and a depressive episode.  The severity of these mood states can range from mild to severe and can alternate gradually or suddenly.

The criteria for a depressive episode remain the same (as above). A manic episode according to the DSM-V consists of the following criteria:

  • Distinct period of abnormally and persistently elevated, expansive, or irritable mood; lasting at least one week and present most of the day.
  • During the period of mood disturbance and increased energy, there is a significant degree of unusual behavior. Three or more of the following symptoms are present:
  • Inflated self-esteem
  • Decreased need for sleep
  • More talkative than usual
  • Flight of ideas
  • Distractibility
  • Increase in goal-directed activity
  • Excessive involvement in activities with high potential for painful consequences

Persistent Depressive Disorder (PDD), formerly known as Dysthymia, is often referred to as a chronic form of depression. While symptoms are less severe than MDD, an episode of PDD can linger for at least 2 years.

Major Depressive Disorder with a seasonal pattern is known as Seasonal Affective Disorder (SAD). This form of depression coincides with the changes in the season (typically fall and/or winter). In order for SAD to be diagnosed, it is imperative that the symptoms that constitute a depressive episode are in complete remission during a characteristic time of year (e.g. depression disappears in the spring and summer).

Therapeutic Intervention combined with psychotropic medication has been proven to be the most effective treatment for depressive disorders. Eighty percent of patients treated for depression show an improvement in their symptoms generally within four to six weeks of beginning medication, therapeutic interventions, and/or support groups. Therapeutic Intervention will not only improve the quality of life for the patient treated but also enhance their ability to cope with a future life crisis.

 The main goal of Therapeutic Intervention (also known as counseling or psychotherapy) is not to "fix" the patient but rather to help the patient cope with their symptoms and gain a confident understanding of their current diagnosis. For the patient, having a good understanding of their symptoms and diagnosis can reduce the anxiety and frustration associated with not knowing why they are going through their current difficulties. Reducing this anxiety and frustration allows the patient to focus on resolving their physical and emotional symptoms.

Therapeutic interventions that therapists use in treatment can vary greatly. Cognitive Behavioral Therapy (CBT) is a widely used evidenced-based module used by many counselors and psychologists. It involves helping patients identify their irrational beliefs about themselves and others (known as automatic thoughts) and develop coping strategies to target and change them.

 Examples of these automatic thoughts experienced by depressed patients can include:

  • "I always fail at everything"
  • "My back is always killing me"
  • "No medication ever works for me"

Although there may be some truth in these automatic thoughts, a depressed patient can unknowingly exaggerate and even distort the reality of their situation. With Cognitive Behavioral Therapy, a patient can learn to recognize and correct these negative thoughts that fuel their depression.

Depression is a disorder with many masks. The disorders ability to cloak itself behind other physical symptoms can make it difficult for healthcare professionals to identify as a primary psychiatric disorder. Education and awareness of the link between physical symptoms and psychiatric disorders are vital in improving patient care. If successfully treated, depressed patients can return to their usual improved emotional and physical functioning. It is important for patients to always remember that depression is a temporary difficulty and not a reflection of their whole life or self worth.

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