Depression

In society today, "Depression" has become a generally accepted term among the lay public and primary care physicians for a condition that requires treatment with antidepressant medication. Every day we are bombarded with direct-to-consumer radio and television ads that provide cursory descriptions of depression and the wonder drugs to fix it...all intended to encourage us couch potatoes to put down our remotes, rush to our doctors, and demand the panacea of our fancy.

Merriam-Webster defines depression as "(1) : a state of feeling sad : dejection (2) :a psychoneurotic or psychotic disorder marked especially by sadness, inactivity, difficulty in thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and sometimes suicidal tendencies". The second definition actually corresponds quite closely with a specific type of mood disturbance classified as "Major Depressive Disorder" by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).  MDD is characterized by a change of previous function brought on by at least 2 weeks of sustained depressed mood or loss of interest/pleasure, as well as a minimum of 4 additional symptoms such as significant weight/sleep/energy disturbances, feelings of worthlessness or excessive guilt, diminished concentration or indecisiveness, feelings of restlessness or being slowed down, inability to experience pleasure, and recurrent thoughts of death or suicide.

Most drug research of depression looks at the effectiveness of antidepressants compared to placebo in the treatment of Major Depressive Disorder. I'm convinced from these studies (especially the non-industry funded ones) and my own practice experiences that antidepressants are beneficial to our patients with MDD.  However, this particular diagnosis may very well represent only a fraction of depressive syndromes that people experience. In fact, the DSM-V includes numerous diagnostic classifications for differential consideration, such as "Depressive Disorder Due to Another Medical Condition", "Substance-Induced Mood Disorder", "Bipolar Disorder", "Cyclothymic Disorder", "Persistent Depressive Disorder" (formerly known as "Dysthymic Disorder"), "Adjustment Disorder with Depressed Mood", "Uncomplicated Bereavement", and "Unspecified Depressive Disorder."  The list doesn't stop there, as many of these diagnoses are further subdivided into multiple distinct entities.  Furthermore, transient depressive symptoms occur commonly in many individuals with personality disorders, which during such times, may resemble Major Depressive Disorder.   

At this point, one might ask and comment, "Aren't these merely esoteric classifications to keep the academicians busy? Psychiatry is not an exact science, after all." Well, actually, there is a method to this apparent madness. While I'll be the first to admit that there exists the potential for significant fudging in diagnosing mental disorders, the purpose of the DSM-V, as explicitly stated in its cautionary statement, is "to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders." Clearly, this is an evolving process, as evidenced by a 5th edition. Notwithstanding, the DSM-V does allow for credible diagnosing in the hands of ethical, skilled, and patient clinicians; and an accurate diagnosis makes all the difference in treatment outcomes.

All too often, I hear reports on the evening news about somebody killing himself or someone else after taking an antidepressant. In our litigiously indoctrinated society, the typical knee jerk reaction to such a tragedy is to conclude that the medication is responsible in some way. Perhaps, but more plausibly as a result of improper diagnosis rather than the drug itself. Without going into detailed descriptions of the various aforementioned depressive syndromes, suffice it to say that for many of them, antidepressant medications may not only be ineffective but also cause further deterioration. For example, when administered indiscriminately to a depressed patient with undiagnosed Bipolar Disorder, antidepressants can unleash a fulminant episode of mania with serious consequences. Moreover, in the unrecognized case of a Mood Disorder due to Hypothyroidism, an antidepressant may result in a transient improvement of depressive symptoms, while delay timely diagnosis and treatment of the underlying medical condition. Frequently, antidepressants are used as poor substitutes for a listening and reassuring confidant to a grieving widow or troubled adolescent adjusting to his parents' divorce.

Unfortunately, Psychiatry has a long way to go in catching up with the other specialties of Medicine, insofar as developing technological assurances for dependable and repeatable identification of specific illnesses. Until then, the time-honored practice of comprehensive history taking, pertinent medical investigation, thorough mental status examination, and judicious application of the DSM-V is our best means of diagnosis for now. Patients and physicians alike should be wary of "mood disorder experts" who rely instead on impersonal and superficial screening instruments. Such charlatans do more to hinder our progress than advance it.

Scott Zentner