A prior post on moderate versus mild symptoms of depression focused on increased sleep and decreased appetite as common vegetative symptoms of depression. I had drawn a distinction between mild and moderate depression as the difference between the severity of physical symptoms, whereas the diagnostic manuals are less specific regarding cognitive and physical symptoms. They tend to focus on the number and severity of both cognitive and vegetative symptoms. I am focusing on what is most apparent to the patient; what actually impels someone to seek professional help. Most depressed people are poorly aware of their cognitive symptoms; especially if they have been manifest for a long time. Physical symptoms are more real and alarming to most patients, than the cognitive symptoms. This does not hold true for severe depressions, as the cognitive symptoms typically outweigh the physical symptoms. Psychotic thoughts and chronic suicidal ideation are two extremely obnoxious cognitive symptoms of depression. I again differ with the diagnostic manuals in that they conceptualize suicidal thoughts as even occurring in mild depression, which I find to not be the case. Severe depressions may manifest psychotic thoughts, and that is in agreement with my experience. The delusional thoughts of the depressed patient are experienced as strange and unwanted, which is a good thing. Truly psychotic individuals have no insight into their malady, whereas the psychotically depressed patient retains their self-awareness. My conjecture is that the primary difference between a mild and moderate depression are the physical symptoms, and between a moderate and severe depression are the cognitive symptoms.
According to the diagnostic manuals, sleep and appetite problems may be present in mild forms of major depression. I find that cognitive symptoms prevail in the milder forms of depression; for example, hopelessness, decreased motivation, sadness, irritability, helplessness, etcetera. The vegetative signs may be present in a mild depression, but are less a focus of the patient’s attention than the cognitive symptoms. The physical symptoms are increasingly noticeable and worrisome in the moderate stage of depression. Typically people are unpleasantly surprised at the level of physical disruption from a moderate level of major depression. A prime example is decreased sleep. This is most noticeable when the patient has a history of good sleep. This may sound obvious, but so many people have insomnia for so many reasons, that disrupted sleep is not unusual to them. Often the person has to experience the reduced sleep for some time before they can differentiate it from common factors that disrupt sleep in their daily lives. Similarly, a person with weight reduction issues may not notice an increased appetite until there is an unusual gain of weight.
If a patient experiences reduced sleep as a consequence of depression, it tends to produce another set of problems. The patient will have difficulty concentrating and sustaining attention throughout their day. They may have brief uncontrolled episodes of unconsciousness, making them dangerous driving an automobile. This nodding off to sleep intermittently is generally not appreciated by their employer, which may increase anxiety about one’s work. Increased sleep secondary to depression presents the greatest risk in terms of missed appointments, whereas decreased sleep appears to this clinician as an even greater functional impairment.
In terms of alterations to one’s appetite, I had focused on a decreased appetite, and the health problems that could ensue. Increased appetite and weight present health problems known to everyone in this day and age. Unfortunately, the average person has learned this message a little too well. Most of the diabetes and atherosclerosis from increased weight is in the morbid range of obesity. A recent very large and well-controlled study investigated survivability amidst groups of people admitted to the hospital for any reason. The investigators found that a patient who is mildly to moderately overweight tended to survive their hospital stay significantly more than underweight and morbidly obese people. The take home message is that mild to moderate weight gain is not likely to pose a medical risk.
It may come as a surprise to many people that in my last twenty years of consultation, nearly all the consults I received regarding weight are for a rapid loss-not a rapid gain. In terms of medical necessity, a rapid weight loss from depression is much more likely in need of treatment than a rapid gain of weight. The greatest problem with rapid weight gain is the functional impairment regarding ambulation and respiration. Both women and men feel worse about themselves after gaining weight, which may deepen the depression. Not being able to play with your children or developing a nocturnal respiratory disorder may further harm and distort a person’s self-image. While unpleasant and embarrassing, increased weight gain from depression rarely presents with the medical necessity of rapid weight loss. Please leave comments regarding this post in the space provided below.