Features of major depression

People with major depression typically have a low mood, loss of interest and enjoyment in activities, and other psychological and somatic symptoms. Other symptoms of major depression include:

  • somatic symptoms
    • changes to weight
    • psychomotor disturbance
    • fatigue and sleep disturbance
  • psychological symptoms
    • diminished concentration
    • low self-esteem
    • excessive guilt
    • feelings of hopelessness and helplessness
  • suicidal thoughts or ambivalence about living.

In children, irritability may be a prominent symptom. Older people with depression may report atypical symptoms, including more physical symptoms and less sadness compared to younger people, although evidence is inconclusive. Psychotic symptoms, melancholic features (see below), insomnia, hypochondriasis and subjective memory complaints may also be more common in older people.

Major depression is diagnosed if a patient has at least 5 depressive symptoms for at least 2 weeks; and at least 1 of the symptoms is either depressed mood, or loss of interest or pleasure in activities.

Depressive symptoms are a feature of many disorders. Consider differential diagnoses in patients presenting with depressive symptoms—see Disorders that can cause depressive symptoms. Thoroughly assess patients with depressive symptoms, including an assessment of suicide risk.

Major depression can be classified as mild, moderate or severe.

  • Mild major depression—symptoms cause distress and the person has some difficulty carrying out usual activities.
  • Moderate major depression—several symptoms may be present to a marked degree and the person has considerable difficulty carrying out usual activities.
  • Severe major depression—symptoms cause considerable distress, agitation or psychomotor retardation and the person is unable to continue usual activities beyond a minimal extent. Somatic symptoms are prominent and suicide is a particular risk. In primary care or community (outpatient) practice, severe major depression is uncommon (less than 5% of those presenting with depression).

Psychotic depression is a rare form of severe major depression in which patients experience psychotic symptoms (eg delusions of poverty, illness or guilt, hallucinations).

Note: In primary care, severe major depression is uncommon and psychotic depression is rare.

Major depression with melancholic features is a debated subtype of major depression that is particularly likely to respond to biological treatment (ie pharmacotherapy or electroconvulsive therapy). Patients tend to experience loss of pleasure in all or almost all activities, marked weight loss, a lack of reactivity of mood, and psychomotor retardation or agitation.