Depressive reactions frequently occur in persons who have a history of manic episodes, butare even more often the sole expression of manic-depressive psychosis. There are three degrees of depression: mild or simple, acute, and stuporous. These divisions, however, merge into each other. The mild type may arise imperceptibly from normal moods and may therefore go unrecognized for some time.The major features of simple depression are inertia, loss of interest and enthusiasm, and physical complaints without organic basis. The patient becomes dejected, thinks of suicide, and finds that speech, work, and eating require more effort than he can manage. He avoids people and sits by himself, obsessed by ruminations about unworthiness, failure, sin, and hopelessness. He usually sleeps poorly, loses weight, suffers from digestive difficulties and constipation, and becomes preoccupied with vague aches and pains. He is likely to believe that his real disorder is physical, and to insist that his feelings of discouragement are merely due to ill health. At the same time he may attribute his ailments to punishment for misdeeds committed in the past. Although he finds thinking and speech difficult, and confines himself to few topics, he does not show any impairment of memory, disorientation, or clouding of consciousness. There is, however, a distinct retardation in thought, speech, and general activity.See DEPRESSION.The retardation is greatly increased in acute depression. Response to questions is slow and hesitant, physical activity is almost at a standstill, and contacts with other people are rarely initiated. The patient is a picture of dejection: his body is stooped, his forehead furrowed, his face troubled, his gaze fixed downward. The vague feelings of guilt and worthlessness of the mild depressive state are now transformed into selfaccusations, and he holds himself responsible for floods, depressions, droughts, and wars. Similarly, his hypochondriacal tendencies now becomeoutright delusions, and he feels that his brain is being eaten away, his innards putrefying, and his bowels stopped up. These delusions may be accompanied by hallucinations, and he usually blames his imaginary ailments on equally imaginary sexual transgressions or other sins. Some patients develop ideas of persecution, and become sullen, morose, and hostile.Patients in an acute depressive state lose all interest in life and, though rarely disoriented, are frequently beset with feelings of unreality. They have an air of resignation, see no hope for the future, and have no confidence in treatment. Many of them try to starve themselves because they feel unworthy of food or simply want to die. They must be constantly watched to prevent suicide.This phase of manic-depressive psychosis reaches its most intense form in depressive stupor. Motor retardation is so complete that there is practically no spontaneous activity or response to external stimuli. The patient is usually mute, confused about time, place, and person, and has either an anxious or masklike expression on his face. At the same time he is preoccupied with delusions, hallucinations, and weird fantasies involving sin, death, and rebirth. He usually has to be bedridden, cannot control elimination, refuses food, and must be tube-fed. He becomes constipated, his breath is foul, and his general health is clearly on the decline.Dlustrative Case: MANIC-DEPRESSIVE REACTION (SIMPLE DEPRESSION)A.B., eighteen years old, is a good example of a simple retarded depression. She had had a former attack one year previously, which had lasted only for about one week, and from which she made, apparently, a good recovery. The family history indicated suicidal tendencies, because a paternal grandmother had taken her life when she was sixty-two years old, and a maternal uncle had committed suicide at the age of forty-five. This family history seemed to have a definite bearing on the case.She had always been a strong, healthy child. She was not nervous, but was quiet, shy, reserved, and not inclined to make friends easily.She did quite well at school, but was described as being more practical than intellectual, and was especially interested in housewifery tasks. It was while she was attending a course of instruction at a School of Domestic Science that she broke down. The illness developed acutely, and three days before her admission she suddenly told her parents that she had chunk a bottle of eye lotion that had been in the house. On the night following this she got out of bed and attempted to leave the house. It is of interest that preceding the onset of her previous attack she had overheard talk about suicide. This reminded her of similar incidents in her own family, and she was depressed for about a week afterward.At the time of her admission she was in a dull, depressed state, feeling hopeless and that she had not been learning and concentrating as she should have done. She feared in consequence that she would become a burden on her friends. Suicide had therefore seemed the simplest solution of her difficulties. She was slow in answering questions, replied for the most part in monosyllables, readily admitted that she was melancholy and that her mind was not at peace, but was occupied with morbid feelings and thoughts. As a result she had not been sleeping well. She said, “I seem just to have been slipping along, and doing my duty. I feel as if I had got everybody into a mess. I thought I was not so efficient as others, and that I could not hold my own with them.” Her answers to questions were always quite coherent and relevant. She denied ever having suffered from ideas of reference, from hallucinations or delusions. Her memory, her grasp on school knowledge, and her intellectual faculties generally were not impaired. She realized that she was ill and in need of treatment in a mental hospital, so much so that she came as a voluntary patient. Her general physical state showed that she was in good condition, and there was no evidence of physical disease. She had an erosion of her lower lip, due to the eye solution which she had swallowed.After a short period in bed she wasallowed up; an attempt was made to cultivate her interest in the occupational department and this she readily took to. She found that she was able to do certain simple pieces of work comparatively well, and in consequence her self-confidence rapidly returned, and in the course of two months she made a good recovery. She put on weight, her sleep improved, she realized more clearly than heretofore what her actual difficulties had been and was able to return home.A case such as the above illustrates very clearly a simple depressed, retarded state, occurring in a somewhat shy, sensitive girl. There is no reason to suppose that she will not be able to carry on satisfactorily in the future. (Henderson, Gillespie and Batchelor, 1962)