THE CLINICAL DIAGNOSIS OF DEPRESSION

The diagnosis of depression has always been – and continues to be – made largely on the basis of a person’s subjective history. Although a skilful clinician will see traces of depression in a person’s face, observe sluggishness or agitation in the body’s movements and hear the slow cadence in the voice, it is the depressed person’s own story that will carry the day in making the diagnosis. A few decades ago there was great optimism that a laboratory test for depression could readily be found. No such luck. For better or worse, in your recollections of how you have been feeling and your accurate take on your present mood you hold the key to determining whether or not you are depressed. What the skilled clinician does is to organize these recollections and evaluate whether or not they meet modern diagnostic criteria for depression.

I remember well, before modern systems of diagnosis had been developed, how the question of diagnosis would be debated in teaching hospitals. A patient would be interviewed and there would be discussion to and fro as to the exact diagnosis. Finally the professor would opine as to whether he (and yes, it was almost always a man) thought that the patient was depressed or not. And his opinion would prevail because he was the boss. Well, clearly that was a most unsatisfactory state of affairs. For clinical, research and, more recently, insurance purposes, it became necessary to define depression.

The latest diagnostic classification system is called DSM-IV, a handbook referred to by insurance companies and others to determine a person’s clinical diagnosis. Each diagnosis is given a specific code number. The diagnosis for many psychiatric conditions, including clinical depression (referred to officially as major depressive disorder), was reached by the so-called Chinese menu approach. In Chinese restaurants, the fixed-price menus permit you to have a certain number of items from Column A, a certain number from Column B and so on. That’s how it is with the DSM-IV criteria for major depressive disorder, which I have modified and listed below. It is worth checking whether you meet the criteria for major depressive disorder. It is important to remember that these are strict criteria.

DSM-IV Criteria for Major Depressive Disorder

A Five (or more) of the following symptoms have been present for two solid weeks. This is different from your usual functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

depressed mood most of the day, nearly every day, either experienced by yourself or observed by others

markedly diminished interest or pleasure in all, or almost all, activities, most of the day, nearly every day

significant weight loss when not dieting, or weight gain, or decrease or increase in appetite nearly every day

sleeping too much or too little nearly every day

being agitated or depressed to such a degree that others could notice it – not just internal feelings of restlessness or being slowed down

fatigue or loss of energy nearly every day

feelings of worthlessness or excessive or inappropriate guilt nearly every day – more than just feeling guilty because your depression doesn’t enable you to function adequately

decreased ability to think or concentrate, or difficulty making decisions, nearly every day

recurrent thoughts of death (not just fear of dying), recurrent ideas of suicide or attempting or planning suicide

AND

B These symptoms cause significant distress or impairment in your social, occupational or other important areas of functioning.

AND

C The symptoms are not directly due to the physical effects of medications, drugs or alcohol, nor the result of a medical condition, such as underactive thyroid functioning.

Now, many people who feel quite depressed do not exactly fit into the DSM-IV criteria for major depression. The diagnostic schema allows for these types of depression as well. These include briefer depressions that occur premenstrually (premenstrual dysphoric disorder), milder depressions (minor depressive disorder), and recurrent depressions that can be very severe even though they may last for only a few days at a time (recurrent brief depressive disorder). The good news is that all of these depressions, as well as those that accompany medical conditions or may be associated with drugs and alcohol, may be helped by the same treatments that are helpful for major depression.

One diagnosis, which has its own code in DSM-IV, is dysthymic disorder, a milder form of depression that causes a great deal of misery because of its chronic nature. I have modified the DSM-IV criteria for dysthymic disorder and have listed these below.

DSM-IV Criteria for Dysthymic Disorder

A depressed mood for most of the day, for more days than not, either experienced by yourself or observed by others, for at least two years

AND

B presence, while depressed, of two or more of the following:

poor appetite or overeating

insomnia or sleeping too much

fatigue or low energy

low self-esteem

poor concentration or difficulty making decisions

feelings of hopelessness

AND

C during the two-year period, you have never been without the symptoms in A or B for more than two months at a time AND

D the symptoms are not due to the direct physical effects of medications, drugs or alcohol or to a general medical condition, such as underactive thyroid functioning.

As you read through the criteria, it will become obvious that they are somewhat arbitrary. What if you were free of symptoms for two-and-a-half months? Does that mean that you are not dysthymic or wouldn’t benefit from treatment? Although systematic diagnostic schemas have been useful for standardizing diagnoses for research and other purposes, the seasoned clinician and the clued-up patient should realize that diagnosis is not a precise science and not get too hung up on whether someone exactly meets the criteria or not before deciding on whether and how to treat.

It is clear that when we are dealing with depression in all its forms, we are dealing with a continuum, with happy normal mood at the one end and serious depression at the other and all sorts of gradations in between. The same treatments that help the more severe forms of depression will generally also help the milder forms and vice versa. The most important determinants of whether or not you seek and receive treatment are therefore how bad you feel and whether you are willing to reach out for help.

*59/75/2*

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