Diagnosis of Depression
In ordinary conversation, nearly any mood with some element of sadness may be called ‘depressed’. However, for depression to be termed Clinical Depression, it must reach criteria which are generally accepted by clinicians; it is more than just a temporary state of sadness. Generally, when symptoms last 2 weeks or more and are so severe that they interfere with daily living (failure to function adequately), someone can be said to be suffering from Clinical Depression.
Clinical Depression affects about 16% of the population at one time or another in their lives. The mean age of onset from a number of studies is in the late 20s. About twice as many women as men report or receive treatment for Clinical Depression, though the gap is shrinking and this difference disappears after menopause. According to the World Health Organisation (2018): “Depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease.”
The DSM view
The Diagnostic & Statistical Manual of the American Psychiatric Association) is one of the 2 leading psychiatric classification systems in the world. Using its terminology, someone with a major depressive disorder can, by definition, be said to be suffering from Clinical Depression.
Just to be clear what we mean by Clinical Depression, it is pertinent to refer to the symptoms described in the DSM-5 (2015). It lists the following:-
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
5 or more of the above symptoms must be persistent for at least 2 weeks and the symptoms causing clinically significant distress or impairment in social, occupational, or other important areas of functioning for diagnosis to be made. Additionally, the symptoms must not be attributable to any kind of substance abuse or better explained by any other medical or psychiatric condition.
DSM-5 represents a shift from the previous DSM-IV-TR (2000). This required the sufferer to have a depressed mood and/or loss of interest or pleasure. For a diagnosis it was sufficient to have either of these symptoms in conjunction with four of a list of other symptoms that included:-
- Feelings of overwhelming sadness or fear, or seeming inability to feel emotion
- Marked decrease of interest in pleasurable activities
- Changing appetite and marked weight gain or weight loss
- Disturbed sleep patterns, either insomnia or sleeping more than normal
- Changes in activity levels, restless or moving significantly slower than normal
- Fatigue, both mental and physical
- Feelings of guilt, helplessness, anxiety, and/or fear
- Lowered self-esteem
- Decreased ability to concentrate or make decisions
- Thinking about death or suicide
The diagnosis did not require “loss of interest in life, anhedonia“. Likewise, “lack of energy and motivation” was not at all a required symptom of a major depressive episode. There were reported numerous problems with diagnosis under DSM-IV-TR, as there still to some degree under DSM-5 Guilt, irritability, aches and pains and, in women, changes in menstrual patterns can be seen as symptomatic or not symptomatic of Depression by different clinicians. Andrew Solomon in his book ‘The Noonday Demon’ (2001, p20) was scathing about the DSM-IV list of symptoms, saying it was: “entirely arbitrary [and] having slight versions of all the symptoms may be more of a problem than having severe versions of two symptoms”.