Wednesday, April 04, 2007

Is depression really depression?


It is not often that I compliment the media. But to give them credit, they have increased the awareness of mental illness in our culture - particularly depression. Whether it's television, movies, radio, or print, I think they have done a good job of decreasing some of the stigma that was out there 30-40-50 years ago.

In a study released in this week's Archives of General Psychiatry, researchers state that 1 in 4 people characterized as depressed are in fact struggling with "normal mental fallout from a recent emotional blow, like a ruptured marriage, the loss of a job, or the collapse of an investment." (New York Times) What?

One of the tools that I have used in the past are some simple one page depression screening tests. Many primary care offices use these checklists - whether they are administered by a nurse or even self-administered by the patient. These checklists can open the door to discussion with the patient/client. Researchers state that these screening tests do not take into account "normal mental fallout."
"Larger and larger numbers of people are reporting symptoms on these checklists, and there's no way to know whether we're finding normal sadness responses or real depression," said Jerome C. Wakefield, a professor of social work at New York University and the study's lead author.
Normal sadness response verses real depression? Mental illness is confusing enough (clinically) with terms like depression, dysthymia, mania, hypomania, generalized anxiety, panic, obsessive compulsive, bipolar, PTSD, and others.
Dr. Darrel Regier, director of research for the American Psychiatric Association, said, "I think the concern this study raises is real, and that we do need to be very careful not to overdiagnose a normal, homeostatic response to loss and call it a disorder."
I think this study will allow physicians and other mental health professionals to brush off depression as only a reaction to a "normal" sad event. This will lead to underdiagnosis (and delayed treatment) of depression. So much has been done in the early identification and discussion of treatment, that I fear this study will negate part of this progress, and allow depression denial to return.

29 comments:

Vinicio said...

people have become so sensative these days. These are indeed normal mental bouts. Depression only exists in the U.S. In others cultures there is no such thing.

Not Nurse Ratched said...

I'm not sure it's a bad thing if people hear a little more "you are feeling sad as an appropriate response to events at hand." We do pathologize normal human response in this society (and medicate too many people---including those with the equivalent of an emotional headache---with dangerous drugs). Americans actually think they are abnormal if they feel sad; they believe they are "depressed" and sick. Clinical depression is no longer differentiated from plain sadness, which everyone now calls depression. I'm glad this study is causing conversation about this.

Rositta said...

Well my mother is very sad right now, is it depression or just the realization that her life is ending? I don't know, do we treat it with drugs? I don't know either. That's the crux of the dilemma isn't it?...ciao

Natalie said...

It makes sense to me as well. I have been very sad and it has made me not want to do things, but I do them. After I wallow a bit I get better. My sister gets depressed. She is unable to get out of bed and ceases to function normally she needs medication to get back to normal. I think the distinction is important. People in this country are used to a quick fix, if they feel a little down they think they need medication. That isn't always the case.

twilite said...

Vinicio, depression exists in other countries especially in the cities of Asia.

Unfortunately, today, there is some confusion on what clinical depression is!

~*SilverNeurotic*~ said...

Regardless if the depression is caused by a stressful event, or is "real" clinical depression it should be treated, either with counseling, or counseling and medication.

Even if it's the event that causes the depression, that depression doesn't always go away without professional care. Therefore it's important to look at depression as a serious issue, and not just brush it off as something that will just go away with time.

And I think you'll agree that there is a distinction between being sad, and being depressed, people have to learn the difference and not over generalize.

gay CME guy said...

There's sadness.
There's organic depression of unknown or unidentified origins, and There's organic depression that can result from chronic or repeated "mental fallouts".
I agree that this country wants to overmedicate everything. We want the 'quick fix' of a 'happy pill', rather than actually deal with the issue(s) that may be at the root of the depression. Meds can help to 'kick-start', someone out of the organic, but it takes more than that. A good shrink can do wonders--with and without meds.

Ami said...

Aren't those check lists often provided by the drug companies? Wouldn't they have a vested interest in a diagnosis of depression? I'm not sure that a check list is a good way to diagnose it. Perhaps having doctors take information as well as asking about recent life events can give a better overall picture.

rdl said...

sounds like semantics to me. Clinical depression is crippling but every day depression(dysthymia even) is debilitating as well. Speaking from experience on both, i say get help wherever you can.

difficultpt said...

Perhaps the diagnosis shouldn't come from primary care. The checklists are good for screening purposes, but perhaps a referral is appropriate . . . Just a thought.

(I was diagnosed with depression, but the depression disappeared when the abuse was absent . . . maybe there should be additional screening if the initial symptoms are present)

Midwife with a Knife said...

I guess this study and the media fallout from it has left me a little confused. Are they saying that we should be more careful about treating depression when it otherwise represents a normal emotional response, or are they saying that people with a distressing grieving response are clinically indistinguishable from depressed folks and that everybody in these groups should be evaluated and treated, but treated according to the level of severity of their symptoms/distress?

Dr. Deb said...

I think when one uses the diagnostic criteria it renders a more valid diagnosis. I worry about the "other" side of things when reports like this come out.

Chrysalis Angel said...

Interesting post Dr.A.. I read this earlier, but really didn't know what to add. Diagnosed with an aggressive cancer young, and diagnosed with 5 other people that died young(one with stage I cancer, and one 4yrs.old) of cancer, I'm surprised I am able to function at all. I've never taken anything for the sleeplessness that treatments caused, nor any mood elevators what-so-ever. I have had moments where I felt I was going to crack, yet held on. You really bring up a thought provoking post. Life events can become overwhelming, but those stressors are from outside sources, you are then forced to cope with, and not internal issues of another origin.

The Peanut Gallery said...

With suicide being one of the leading causes of death in the US, we need to screen for and treat mental illness. Sometimes there can be a stressful event that makes a depressed person be non-functional and need to finally seek treatment.

Anonymous said...

Nice post Dr. A. I think sad mental fallouts can lead to depression very easily. I sometimes feel sad and I am not doing things happily which I diagnose as sadness then in a short while I feel that I don't have the desire of doing anything except sleeeeeeping & only sleeeping & here I feel it's depression. However the only thing that gets me back to normal is the faith in GOD.
Just A reader

SeaSpray said...

Hi Dr A - There are so many variables. There does seem to be more stress today and I do think there is a difference in the depression one feels that is a reaction to events or circumstances, that sense of powerlessness when something is taken away or some tragedy rocks your world.

It's normal to feel melancholy once in awhile, but if a person wants to remain in the fetal position under the mattress for days art a time, then I think it is time for some intervention, some professional help. I think counseling first. Sometimes if a person can just feel heard and maybe validated - it can do wonders.

On the one hand it is difficult for you to evaluate which patients are clinically depressed because so many seem to fit into that category, but I wonder how many go undetected because they are from our parent's generation that just kept a stiff upper lip and just did what had to be done? They don't believe in telling their private info but live in quiet desperation.

I do think antidepressants or anti-anxiety meds have there place, but sometimes I think they are used like a bandaid placed over a festering wound.

Counseling and meds (if necesary)optimum choice so patient can work through issues and monitored physically as well.

Sorry if I digressed. :)

DrGwenn said...

Seaspray raises the key point for me - stress is on the rise for most folks, including kids. I'm a big believer in cognitive therapy and exercise - that can do wonders for everyone's frame of mind.

I do believe clinical depression is real but I also have felt for a long while that we are failing those that hit a hiccup in life by labelling them as depressed. People never get a chance to realize their innner strength if they are just labelled and medicated.

patientanonymous said...

I think there can be a tendency to over-medicate and perhaps prescribe too freely but the pendulum can't swing too far in the other direction. You really need to treat everyone individually, on a case-by-case basis and look at what is occurring and monitor each patient--very carefully. You don't want to mess around here.

You have to take into account histories and yes, perhaps a stressful event that could act as a trigger for maybe an underlying condition that now may be surfacing.

On the flipside, it could be a period of great difficulty and the person may not need meds but could need therapy or counseling. Or may even need meds temporarily. I once met someone who after a very difficult life circumstance, went on an MAOI for a year and was "back to normal" after that.

Again, each case is different and needs to be handled with care.

~*SilverNeurotic*~ said...

Happy Easter!

Anonymous said...

I consider myself to be a normal, optimistic, roll-with-the-punches sort of person, but I've also been clinically depressed and it totally sucks. You wonder why you just can't snap out of it and get on with life. Just want to be left alone and get angry and irritated at life for intruding. Bursting into tears at something as stupid as a vacuum that didn't shut off when you hit the switch. You have no idea why you feel so out of control and helpless and sad when you're normally NOT LIKE THIS. Depression is way more than stress, way more than sadness.

I *do* think, however, that depression can result from life's stresses, as I do think stress does deplete your brain's serotonin levels.

For me, anti-depressants weren't a 'happy pill.' They lifted the depression and made me feel NORMAL, like my usual self.

Is depression over-diagnosed? Probably. But after living with it, you betcha it's a real illness.

sarala said...

Some of the comments here make me cringe. Thanks for bringing a measured view out there. We need more primary care docs like you (that is what you are?) Depression and other mental illnesses exist in many (all?) cultures, they are just expressed and experienced in different terms based on culture.

Bankerchick said...

A good post and well thoughtout comments. My husband of 39 years was recently diagnosed as clinically depressed and has been place on medication that really helps along with therapy. He has always had what I'd referred to as melancholic personality that got better when he quit drinking altogether 25 years ago. When he started thinking life was maybe not worth it about 2yrs ago. I was galvanized into action and we went to his DR, who placed him in a facility as an outpatient and they placed him in therapy and a psychiatrist placed him on medication. Now when my mom passed away 4 years ago, I was sad, not sleeping well and the Dr put me on Paxil for a short time. It helped but the grieving process is over and I don't need it any more and to be honest, probably did not need it then, eventually I would have started sleeping better and go over being sad, probably....I won't know for sure.

may said...

dr. A, my comment is VERY long, so i just posted it on my blog.

may
www.aboutanurse.com

Dr. A said...

Don't take this the wrong way. I don't want to sound upset, because I'm not.

But, just an observation, but I find it interesting how many people associate treatment with prescription medications.

My concern with this study is that it may lead to under-RECOGNITION and under-DIAGNOSIS of depression and mental illness.

Personally, I don't care how it's treated - meds or no meds; counseling, therapy, or just self-awareness of the situation. Treatment, of course, should be individualized to the patient.

With regards to using screening tools and/or referral to psychiatry, in my large county where I practice, we only have three psychiatrists, and it can take months for a patient for a referral. So, at least here, it falls on the primary care doc to make the diagnosis and start initial treatment (whether that be counseling, meds, alternative therapies, etc).

Anonymous said...

Some of these comments make me cringe, too, as it further stigmatizes mental illness to say that it only exists in the U.S. ...that is quite an ignorant thing to think. Clinical depression is as real as heart disease, cancer, diabetes, etc...when will people realize this and stop the prejudice against the mentally ill??

health watch center said...

Depression exists all over the world...in some countries they don't know what is that...

The way you react to stress factors in on how you feel. You could feel depressed, if you react to stress in negative light. Stress is a part of life and hits us every single day we live. There is no escape for stress.

Stress overall is changes small and large in which you must regulate to its actions. Most people believe stress is a negative act. However, stress can work in your favor. Stress coming from injury, illnesses, and death can also be, turned into positive influences.

Self Help Zone

drytears said...

If this is true and being reported to the public... I would expcet more people to hide how they are truly feeling simply because its a 'normal' response. Also if some one really is depressed and it's down played saying it's 'normal' to feel that way it's like blow to the face because it probably took a lot of strength to ask for help and then it's downplayed.

mac said...

The spreading rate of depression is very large to alcohol drinkers, as compared to others.
The depression affects the mental health and cause many problems.
The peoples have more work load, so they live tension life.
According to the article, the depression is really a depression...
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mac
Dual Diagnosis
Dual Diagnosis

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