The word 'depression' is such a confusing term. It is used frequently in day-to-day conversation and it is also used in what is intended to be a more precise clinical way by doctors and psychiatrists.
According to the psychologist Martin Seligman, people born since 1945 are 10 times more likely to suffer from depression than those born before.
Depression has been described as the number 1 psychological disorder in the western world. It is said to be growing in all age groups, in virtually every community, and the growth is seen most in the young, especially teens. At this rate of increase, it will be the 2nd most disabling condition in the world by 2020, behind heart disease.
But because the word depression is used so freely and interchangeably in many different ways we need to be careful to explain what we actually mean by the D word.
It is very common to complain of or go to the doctor with feelings of sadness or distress in some way. These feelings may be a result of grief and/or other stresses in life. This can also include physical illness. Sometimes feelings of sadness appear 'out of the blue' with no obvious relationship to anything going on in the person's life.
So we can say that there appears to be a spectrum of mood disturbance that can range from mild to severe and from short-lived episodes to long periods of unremitting illness.
Depression was recorded by the ancient Greeks, the Bible and Shakespeare, but it was only relatively recently in 1980 that a formal definition came into being. This was when the American Psychiatric Association produced what is called the Diagnostic and Statistical Manual for Mental Disorders 3rd edition (DSM- III).
Since then the DSM has from May 2013 published a 5th edition (DSM-V). This lists the following criteria for the diagnosis of what is called a 'major depressive episode':
According to the DSM at least 5 of the following 9 symptoms need t0 be present for a 2 week period or longer:
- Depressed or irritable mood most of the day, nearly every day (that is feeling sad, empty or tearful)
- A diminished interest or pleasure in all, or almost all, activities for most of the day nearly every day (psychiatrists call this anhedonia).
- Significant and unintended weight loss or weight gain (this is usually accompanied by a change in appetite)
- Extreme fatigue or loss of energy
- Significant changes in patterns of sleep (either too little or too much sleep.
- A slowing down of behaviour and speech that is noticeable by others (called psychomotor retardation) or the opposite of extreme agitation and restlessness (called psychomotor agitation).
- Feelings of worthlessness or guilt that are excessive and unwarranted.
- Difficulty concentrating and making decisions.
- Recurrent thoughts of death or suicide and/or making a plan to commit suicide.
Using the DSM-V to receive an official diagnosis of major depressive episode there are a further 3 requirements:
- One of the 5 symptoms has to be either depressed mood or loss of pleasure.
- The symptoms have to represent a change from the person's normal level of functioning.
- The symptoms have to cause sufficient problems or distress in the person's life. This could be in the areas of making or keeping relationships or fulfilling work obligations.
From this point the depression is then classified as mild, moderate or major depending on severity.
But whether depression is classified as major, moderate or minor, as far as the person is concerned its all major.
Rather like all minor surgery if it is happening to you personally then it is major surgery!
There is also a 2nd classification system called the ICD (International Classification of Diseases) of which the 11th editions is due for publication in 2017. The ICD classification is produced by the World Health Organisation. It is very similar to the DSM.
So that is how psychiatrists and doctors diagnose depression, but it still poses many challenges to making sense of what we exactly mean by the D word.
Both the DSM and ICD aim to set strict criteria for identifying disorders of the mind such as depression. You would think that such an approach would make diagnosis more reliable, but in fact there is much criticism about both these systems.
So for example why were 5 of the above symptoms chosen and not say 4 or 6? Why 2 weeks and not say 3 weeks? The decision to go for 5 symptoms over 2 weeks was a purely arbitrary one. That means anyone who is consistently unhappy for a fortnight and also has other symptoms, such as complaining of poor sleep and loss of concentration could be diagnosed as having a major depressive episode. It also means the prevalence of the condition is very high at up to 50% over any single person's lifetime!
That also explains why there are understandable fears about wrongly diagnosing, over diagnosing people and then medicalising so called 'normal' behaviour.
As a case in point, DSM-V has softened a number of exclusion criteria, particularly the one for grief. The implication is that any symptoms that last for more than 2 weeks must be an abnormal response. There are genuine fears that what is a normal human experience of grief can be medicalised into an illness.
So why is the diagnosis of depression increasing so much?
It would appear to be the result of the combining together of two different categories of sadness and depressive disorder.
According to a British Medical Journal review by Dowrick and Frances (2013) over diagnosis is more common than under diagnosis. They quote a study where only 38% of adults with "clinician identified depression" actually met criteria for depression.
We will explore this in future posts.
The 4 minute 'I had a black dog' video gives a powerful subjective explanation of what it feels like to grapple with depressive feelings. I have also talked about my own personal struggles with depressive feelings in the 15 minute video, 'Just As I Am'.
The reality of depression as an important issue in modern life is something we as a society need to face up to. (See the 3 minute video 'Facing Up to Depression'). The author Simon Sinek has written about the dramatic increase in suicide over the last few years in the baby boomer generation (see 'How to Fail and Lose Well Part 2').
What questions do you have about the diagnosis of depression?