Depression is a disorder of the brain and
body's ability to biologically create and
balance a normal range of thoughts,
emotions, and energy. In its full syndromal expression, clinical depression manifests as major depressive disorder, with
episodic course and varying degrees of residual manifestations between episodes.
Symptoms, Signs, and Diagnosis
The mood is typically depressed, irritable, and/or anxious. The patient may appear miserable, with furrowed brows,
downturned corners of the mouth, slumped posture, poor eye contact, and monosyllabic (or absent) speech. The
morbid mood may be accompanied by preoccupation with guilt, self-denigrating ideas, decreased ability to concentrate,
indecisiveness, diminished interest in usual activities, social withdrawal, helplessness, hopelessness, and recurrent
thoughts of death and suicide. Sleep disorders are common. In some, the morbid mood is so deep that tears dry up;
the patient complains of an inability to experience usual emotions--including grief, joy, and pleasure--and of a feeling
that the world has become colorless, lifeless, and dead. For such patients, being able to cry again is usually a sign
Melancholia (formerly endogenous depression) has a qualitatively distinct clinical picture, characterized by
marked psychomotor slowing (of thinking and activity) or agitation (eg, restlessness, wringing of the hands,
pressure of speech), weight loss, irrational guilt, and loss of the capacity to experience pleasure. Mood and
activity vary diurnally, with a nadir in the morning. Most melancholic patients complain of difficulty falling asleep,
multiple arousals, and insomnia in the middle of the night or early morning. Sexual desire is often diminished or lost.
Amenorrhea can occur. Anorexia and weight loss may lead to emaciation and secondary disturbances in
Some experts consider psychotic manifestations, which occur in 15% of melancholic patients, the hallmark of
a delusional or psychotic depressive subtype. Patients have delusions of having committed unpardonable sins or
crimes; hallucinatory voices accuse them of various misdeeds or condemn them to death. Visual hallucinations
(eg, of coffins or deceased relatives) occur but are uncommon. Feelings of insecurity and worthlessness may
lead some patients to believe that they are being observed or persecuted. Others think that they harbor incurable
or shameful disorders (eg, cancer, sexually transmitted disease) and that they are contaminating other persons.
Very rarely, a person with psychotic depression kills family members--including infants--to "save" them from future
misfortune and then commits suicide. Dexamethasone suppression test results are consistently positive in patients
with psychotic depression.
In atypical depression, reverse vegetative features dominate the clinical presentation; they include anxious-phobic
symptoms, evening worsening, initial insomnia, hypersomnia that often extends into the day, and hyperphagia with
weight gain. Unlike patients with melancholia, those with atypical depression show mood brightening to potentially
positive events but often crash into a paralyzing depression with the slightest adversity. Atypical depressive and
bipolar II disorders overlap considerably.
The diagnosis of clinical depression is usually straightforward, but recognizing low-grade symptoms may be
difficult. For example, in major depressive disorder with incomplete recovery, classic depressive symptoms recede
and are replaced by subacute or chronic hypochondriacal concerns, irritable morosity, and secondary interpersonal
trouble in conjugal life. In other patients, considered masked depressives, depression may not be consciously experienced.
Instead, patients complain of being physically ill and may wear a defensive mask of apparent cheerfulness (smiling depression).
Others complain of fatigue, various aches and pains, fears of calamity, and fears of becoming insane. REM latency
is shortened in these patients, supporting the affective nature of the clinical presentations.
Diagnosis is based on the cluster of symptoms and signs described above and should be considered in all
patients, particularly those who say that they do not deserve to be treated or refuse to cooperate with medically
needed procedures or treatments.
Muslim with depression should try if at all possible to find a Muslim doctor practicing in the field of psychology to
obtain treatment. This is important so that Islamic remedies can also be stressed and the importance of following the
Qur'an and the sunnah wil not be overlooked. If a doctor cannot be found, then it may be helpful to get counseling from
a Muslim sister or brother with counseling experience.
Most persons with depression are treated as outpatients. Pharmacotherapy, delivered in the context of supportive
therapy and psychoeducation, is the treatment of choice for moderate to severe depression; milder depression can
be treated with psychotherapy. All patients with depression must be asked gently but directly about suicidal ideation,
plans, or activity. All communication of self-destruction should be taken seriously.
Initially, the physician sees patients with depression weekly or biweekly to provide support and education about
the disorder and to monitor progress. During the early phase of treatment, keeping in touch with the patient and
family via a few telephone calls may help. Because many are embarrassed and demoralized by having a mental
disorder, the patient, his family, and his employer (when appropriate and after obtaining informed consent from the
patient) should be told that most often, depression is a self-limiting medical disorder with a good prognosis. Some
patients may find the diagnosis of depression unacceptable, and the physician should reassure them that depression
does not reflect a character flaw, giving some explanation of the biologic disturbances of depression.
Specific advice to patients often helps. It includes telling them to be as active as possible, but to not take on
insurmountable tasks; to try to be with other people; not to blame themselves for being depressed; and to
remember that dark thoughts are part of the illness and will go away. Significant others should be told that
depression is a serious illness requiring specific treatment; patients with depression are not lazy; loss of love
or job is often the result, not the cause of depression; religion may comfort but does not cure; exercise is not a
treatment specifically geared for depression; and vacations may make depression worse. (Compiled from
information in Merck Manual 17th edition.)
Please Note: As with all depressive illnesses, it is important that Muslims attempt to get advice from a Muslim
psychologist, psychiatrist, physician, or counselor. For patients that are unable to find a Muslim physician in
their area specializing in psychology, it would still be helpful if they were able to consult with a Muslim clinician
and receive advice or assistant with ensuring that the treatment program outlined is in accordance with Islamic principles.
Checklist for Signs of Clinical
If you answer "yes" to more than two of the following questions, you may be suffering from clinical depression:
1. Much of the time, do you feel...
2. Much of the time, do you...
have difficulty making decisions?
have trouble concentrating?
have memory problems?
3. Lately, have you...
lost interest in things that used to give you pleasure?
had problems at work or in school?
had problems with your family or friends?
isolated yourself from others, or wanted to be isolated?
4. Lately, have you...
felt low energy?
felt restless and irritable?
had trouble falling asleep, staying asleep or getting up in the morning?
lost your appetite -- or gained weight?
been bothered by persistent headaches, stomach aches or back aches?
been bothered by muscle or joint pains?
5. Lately, have you...
been drinking alcohol (which is haram in Islam)?
been falling into sins and sinful activity more easily?
engaged in risky behavior, such as not wearing a seat belt or
crossing streets without looking?
6. Lately, have you been thinking about...
If you are uncertain about your state of mind, I would recommend seeking the opinion of a Muslim physician or health care provider who could direct you to some counselling resources in your area.