Psychiatric diagnosis is badly in need of shaking up, but it didn’t happen in the new DSM-5 launched several months ago. The new edition of the Diagnostic and Statistical Manual just trims at the edges of the hundreds of diagnoses in this giant colossus while failing to come to grips with the commonest diagnosis in psychiatry: depression.
There is such a thing as real depression. It’s called melancholia. The patients are unutterably sad, slowed in thought and movement, often believe they have sinned unpardonably in the past, that the present offers no pleasure – this is called anhedonia --, and that the future is without hope. No wonder they often kill themselves.
But veteran psychiatrists estimate that only about a quarter of patients with the diagnosis of depression have melancholia, a homogeneous biochemical entity. Most other patients with the depression diagnosis have something else going on. They aren’t necessarily sad. One in five Americans will get the diagnosis of depression at some point in his or her lifetime. Yet, according to the National Center for Health Statistics, only 3.2 percent of the U. S. population in 2011 were sad all of the time or most of the time. (JS Schiller et al., 2012, p. 55) (Only 2.2 percent felt hopeless, 1.9 percent worthless.) It is impossible to reconcile these figures with the one-in-five claim.
Instead, people with the depression diagnosis may have a problem with “nerves”; and a real problem, that leaves you unable to go to work and shatters your marriage, is called a “nervous breakdown.”
How is the nervous breakdown different from depression? There are two kinds of depression. One is melancholic, the deep sadness, the slowed thinking, the despair. This is the same thing as a nervous breakdown, though other illnesses, such as extreme panic, can cause breakdowns as well.
The other kind of depression is much more than a mood disorder, more than sadness; it involves anxiety; it involves crushing fatigue; it involves bodily woes that come and go. This is way beyond the concept of mood because the patients may not be sad. “Nerves” is a good, sturdy, old-fashioned term for it.
The core of the old nerves diagnosis was mixed anxiety-depression, which was the commonest mood diagnosis in psychiatry in previous decades. Mixed anxiety-depression started out in the 19th century as “neurasthenia,” literally tired nerves, then morphed into “reactive depression” and “neurotic depression” in the 1920s as the focus in psychiatry shifted from physical emphasis on the nerves to the emotions, which means mood and affect (mood is the deeper, affect more the day-to-day state of mind).
People still talk about nervous breakdowns. Comedian Jonathan Winters, we learned the other day in an obituary, suffered in 1959 from a ”nervous breakdown.”
But nerves has gone off the boards, and in the 1920s the term vanished from medicine. Today, it sounds just too antique for words: somewhere between hysteria and mustard plasters.
So what is going on with all these depression patients who are not melancholic?
For one thing, they may have one of the D-words, meaning demoralization, disappointment, or discouragement. But students of psychopathology, the fine analysis of patients’ signs and symptoms, do not see the D-words as synonyms of depressed mood, and these terms are certainly not the same thing as the sadness of melancholia, a debilitating disorder.
As well, patients with the depression diagnosis are often tired, even desperately weary. In a study by the Depression Research in European Society group (DEPRES) in 2000, 73 percent of respondents with depression said they were tired (Tylee, 2000)
What else? It is just super-common that “depression”-diagnosis patients have a riot of somatic symptoms, meaning pains here and there – they start out seeing family physicians and internists; and they tend to obsess about the whole package.
This is more than a mood disorder; it is a total body disorder. And the severe version of it was called the nervous breakdown.
Neither of these depressions – melancholia or nerves -- is reflected in DSM. But both are real illnesses, and correspond to problems that people actually have. You as a physician can recognize your patients in them. It’s harder to see your patients in such DSM terms as “major depression” or “general anxiety disorder.”
Nerves, mixed anxiety-depression, non-melancholia: These are all more or less the same thing. DSM-style psychiatry has removed all the contents of the former nerves basin until only “depression” is left – and it’s an undifferentiated depression that lumps together psychiatry’s two depressions, melancholia and non-melancholia.
But the real question is: So what? Why do these arcane diagnostic distinctions matter?
They matter because diagnosis determines treatment. And the treatments for melancholia and non-melancholic “nerves,” or low-level depression, are different.
The treatments for low-level nervous depression had once been barbiturates and amphetamines. After the 1960s, the Valium-style drugs, called the benzodiazepines, were highly successful for mixed anxiety-depression; now the benzos are seen, incorrectly, as terribly addictive and are much less prescribed.
But here we’ve lost something: Prozac was introduced in 1988 and, together with such cousins as Zoloft and Paxil, swept all previous mood agents from the table. It was a massacre of the effective drugs. To be sure, the Prozac-style pharmaceuticals are useful for anxiety, but they are not really “antidepressants.”
The treatments for melancholic depression – the nervous breakdown -- are completely different. And here again, a group of effective agents have been getting short shrift.
In the 1950s, several beneficial drug categories for serious depression were introduced. The first of these, the monoamine oxidase inhibitors (MAOIs) were launched in the early 1950s; the highly effective drug Parnate (tranylcypromine) appeared in 1961. The tricyclic antidepressants, so-called because of their chemical structure, reached the American market in 1959; many older psychiatrists still believe that the first of these tricyclics, Tofranil (imipramine), was the most effective antidepressant ever. Shock therapy, known technically as electroconvulsive therapy (ECT), the most powerful treatment psychiatry has on offer, was introduced in 1938 and in the 1950s was seen as a safe and effective treatment of depression. These have all been greatly diminished now (though ECT is still available in specialist psychiatric hospitals), and if you get depressed today, the chances are you won’t receive any of them.
Now everybody gets the same diagnosis, major depression, and they get the same treatment, the Prozac-style antidepressants and their cousins. According to Decision Resources, in 2001 the Prozac-style agents constituted 46.2 percent of all antidepressant sales; the drugs that act both on serotonin and norepinephrine, 18.5 percent; and the other “second generation” antidepressants 13.7 percent, just to mention some categories. Meanwhile, the market share of the truly effective anti-melancholics had dropped to a tiny proportion of all sales: 1.2 percent for the tricyclics, and 0.8 percent for the monoamine oxidase inhibitors. The most effective sold the least! (decisionresources.com)
This is a scientific travesty. Major depression is a highly heterogeneous category lumping together patients with serious melancholic depression and the patients with mixed anxiety-depression and fatigue formerly known as nervous. They all are prescribed the Prozac-style drugs. This means that individual patients with “major depression” may be getting the wrong treatment – because they’ve got the wrong diagnosis. Those within the “major depression” pool who have mixed anxiety-depression may respond suitably to Prozac and its cousins, but those whose depressive illnesses run deeper, probably won’t.