Case history
Case history
A 35-year-old woman presents with a 1-month history of poor sleep and irritable mood, in the setting of a recent divorce and ongoing custody battle with her former husband over their two teenage children. She has also just had a bad performance review at work due to her inability to meet deadlines and is fearful of losing her job. She explains that her work problems have arisen because she has been unable to keep her concentration focused on work. She expresses feelings of worthlessness and wonders sometimes what is the point of living. She has to force herself to stay engaged in her children’s activities and other interests that she used to enjoy; she feels she is 'just going through the motions'. She had a similar episode after the birth of her second child, but pulled out of it after several months. There is a family history of suicide; her mother killed herself when the patient was 10 years old. Her examination is notable for poor eye contact and frequent tears. Her test results, including the thyroid-stimulating hormone, are normal.
Other presentations
Although core features of depression appear to be relatively consistent across different cultures, a number of key points of cultural variation have been noted; for example, sadness may be less of a prominent symptom in some cultures, and differences in expressing emotions may result in underreporting of emotional and cognitive symptoms in some cultural groups compared to somatic symptoms.[7] Somatic symptoms (e.g. headaches, generalised aches and pains, palpitations, tremor, blurred vision), although not comprehensively described in current established diagnostic criteria, are commonly reported symptoms of depression across a number of different geographical populations, including people from Africa, Asia, Central and South America and the Pacific Islands, but may occur in people with depression regardless of their location or culture.[8][9]
In a minority of people with depression, and more commonly in men, externalising features may be present, for example, anger, aggression, substance use problems, and risk-taking behaviour.[10]
In older people, depression can present as diminished self-care, psychomotor retardation, irritability, and apathy. These patients may also present with severe cognitive disturbance (memory deficits) as a result of the depression. Older people may also be more likely to have single or multiple comorbidities that contribute to the development of depression (e.g., malaise from medical illness or side effects of non psychiatric medications).[11]
Women in the perinatal period are at high risk for depression.[12] See Postnatal depression.
Patients with diabetes, cancer, stroke, myocardial infarction, obesity, and other general medical conditions have significantly higher rates of depression than people without comorbid conditions and may present atypically with non-adherence, multiple unexplained symptoms, or chronic pain syndromes.[13][14][15][16]
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