Depression: A Symptom, Not a Disorder
Over-diagnosing clinical depression has spurred inappropriate treatment.
Posted Dec 15, 2017
Lately, there has been a large number of articles about "depression" that seem to go out of their way to avoid mentioning any specific psychiatric diagnosis listed in the profession’s diagnostic manual, the DSM. They strongly imply that "depression" is itself a disorder. These articles appear not only in the popular press but, frighteningly, in newsletters and newspapers for physicians and psychologists. They explore such questions as "Do antidepressants work?" and "Which is better for depression, drugs or cognitive behavioral therapy?"
These types of questions are often completely meaningless. Depression is being discussed as if it were a single phenomenon that, at best, exists on a continuum from "mild" to "moderate" to "severe." This type of wording is in many cases used to mislead readers. Different entities, such as pharmaceutical companies and specific psychotherapy schools of thought, have a vested interest in conflating several different psychiatric conditions in order to make money.
"Depression" is just a mood state and as such merely a symptom of something else. As a symptom, it can be part of many different psychiatric disorders that are, despite some overlap in their other symptoms, as different as night and day when it comes to their clinical presentations as well as their response to various treatments.
To name the actual diagnoses of which depression is a symptom, there is major depression (both as part of unipolar and bipolar disorder), dysthymia, adjustment disorder with depression, depression due to a medical condition, and depression due to a substance.
Medical conditions that can lead to depressive symptoms include hypothyroidism and some strokes. Substances that can do that include some steroids like prednisone and the "crash" that results when a cocaine or amphetamine high wears off.
Of course, "depression" as discussed in everyday conversation can also be a normal part of chronic unhappiness, or that occurs in response to grief at someone's death or due to any other loss or misfortune.
The most important diagnostic distinction for purposes of this discussion is between major or clinical depression and dysthymia. Although we do not know enough about the brain to know the exact causes of either one, and there is some overlap in symptomatology, they are characterized for the most part with very distinct clinical presentations, especially in their classic forms.
Dysthymia appears to be more of a psychological reaction, while major depression probably involves malfunctioning of the more primitive part of the brain called the limbic system. The latter, unlike the former, is accompanied by a whole array of chronic, persistent (lasting almost all day long every day for at least two weeks), and pervasive (coloring all aspects of the patient's mental life) physical symptoms involving sleep, appetite, ability to experience pleasure, energy level and motivation, and concentration.
These symptoms must all be present at the same time. We used to refer to them as vegetative symptoms. Sufferers may have an unrelenting and constant sense of foreboding accompanied by inexplicable hopelessness and helplessness.
Furthermore, someone with a major depressive disorder episode reacts completely differently to life's everyday ups and downs than they do when they are not in the middle of such an episode. It's almost Jekyll and Hyde territory.
These people stay depressed no matter what life events are occurring around them. They could literally win the lottery and not really feel a whole lot better for more than a few minutes.
The most severe form of major depression is called melancholic depression. Most people who have never worked in a mental hospital have never seen a case. People with melancholic depression exhibit something called psychomotor retardation. People with this symptom move and think at a snail's pace. It takes them longer to respond to any verbal interactions. They can even appear to have significantly impaired memory, although it is actually a more severe form of impaired concentration. That clinical picture is sometimes referred to as pseudodementia.
You cannot spend more than an hour with such people without realizing that this condition has next to nothing in common with the type of "depression" people see in their everyday interactions with others and that there is something seriously wrong with the way their brains are functioning.
In severe major depression, doing any kind of psychotherapy (short of telling them, "take these pills") is a complete and utter waste of time. And I say that as a major advocate of psychotherapy. Sufferers do not have the mental wherewithal to deal with any kind of problem-solving or other interactions with a therapist.
The symptom of depression in dysthymic disorder, on the other hand, rarely responds to antidepressant medication much at all (although the drugs can be useful for other symptoms and conditions seen in patients with dysthymia such as panic attacks, obsessive ruminations, and the affective instability characteristic of borderline personality disorder). For these folks, psychotherapy is the essential treatment.
In my experience, a very high percentage of the people who do drug and psychotherapy outcome studies, at least in adults, make almost no meaningful effort to differentiate dysthymia from major depression by:
1) Not spending any time making certain that patients understand the pervasiveness and persistence criteria that differentiate the symptoms of the two disorders, and by
2) Not taking a complete biopsychosocial history to distinguish purely psychological from limbic system factors.
Furthermore, with the private Contract Research Organizations that do a lot of the drug studies, experimenters get paid only if they recruit a subject, and subjects get paid only if they get recruited, providing a financial incentive for everyone to exaggerate symptoms in order to qualify.
In drug and psychotherapy studies, people with suicidal ideation, comorbid (other, co-occurring) conditions, and significant personality pathology are almost always excluded from studies. Those "exclusions" eliminate the vast major of subjects that have any of the psychiatric disorders in which depression is a symptom.
Garbage in, garbage out.
By the way, you can also have something called double depression. Such people are generally dysthymic but every so often can have a superimposed episode of major depression. So they have both conditions.
Once a major depressive episode starts to occur, it takes on a life of its own. However, being chronically unhappy, anxious, or stressed out may be risk factors for triggering a major depressive episode, to begin with. If you are genetically vulnerable to an episode of major depression, being chronically unhappy might makes an episode more likely.
This is another reason why the question "Should you treat these people with medications or therapy" is a really stupid question. It is a bit like asking, "Which treatment should people who have extensive, severe, cardiovascular disease get, bypass surgery or high blood pressure medication?"
These treatments address completely different aspects of the disorder. In major depressive disorder, drugs should be used during the acute disorder, but psychotherapy should be given later to address personality and relationship risk factors, in order to reduce the likelihood of subsequent episodes.