Note: the source material for all facts cited here can be found in the book, Undoing Depression, 2nd edition.
Diagnosis in psychiatry is currently based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, commonly known as DSM-IV. The process of arriving at a standard nomenclature for emotional conditions and mental disorders has been complex, partly because so many of the conditions are themselves controversial topics in contemporary culture: Is alcoholism a disease, a habit, or a weakness? Is bulimia a disease, or a cultural conflict about what the female body should look like? Why do Vietnam vets apparently suffer from Post-Traumatic Stress Disorder at such higher rates than soldiers in previous wars? Should rebellious adolescents be hospitalized against their will because they can’t get along with their parents? Should people with chronic substance abuse problems be considered disabled, and thus entitled to Social Security benefits? These questions require answers that make us question our deepest values—do we have the ability to make our own decisions in life, or are our decisions programmed by our heredity, nervous system, or early childhood experience? If our decisions are determined, what happens to the social contract, guilt, crime, and punishment?
Depression as a diagnosis has not pushed quite so many of society’s hot buttons, but it is subject to the same controversies. The DSM, for research and validity purposes, has followed a strictly phenomenological approach: if a symptom cluster was observed commonly enough to be a problem perhaps worth addressing, and if observers with the same training could reliably identify the same symptom cluster with the same patients, that symptom cluster was given a name. There might or might not be a good explanation, a theory, for why that particular group of symptoms seemed to occur reliably together. Certainly it was the hope of the compilers of the new DSM that a reliable classification system, in which we could all be sure we were counting and observing the same things, might lead to better explanations for the underlying mechanisms beneath the symptoms, and improvements in treatment.
But this approach has also had its drawbacks. It has certainly contributed to the medicalization of complex emotional/behavioral states, like alcoholism, depression, or Post-Traumatic Stress Disorder. It led insurance companies to go along with the idea that an expensive course of hospital-based treatment was appropriate for these conditions, contributing to our current backlash of attempts to overcontrol behavioral health care costs. It has led to absurd legal strategies by defendants who eschew responsibility for their actions. Most tragically, by making these conditions “diseases,” it has led to patients hoping that the cure for their condition will come about from a new pill, and the belief that until the pill comes along there is nothing they can do to help themselves.
In the case of depression, the phenomenological approach has also led to some hair-splitting in diagnosis that emphasizes artificial distinctions, minimizing commonalities and contributing to the trivialization of research. Currently, the DSM-IV recognizes several distinct depression-related diagnoses, which we will describe along with what we know of their frequency and prevalence. The caveat is that the formal requirements for a diagnosis are often arbitrary by nature. The DSM was designed to be a research tool leading to further refinement of diagnosis, not the bible it’s become to many people.
Major depression is a very serious condition. Usually the patient and family recognize that something is gravely wrong, but exactly what it is is not so easy to tell. In the simplest case, the patient feels, looks, and acts depressed, and tells people about it.
Nancy has major depression. Although she is able to hold down a responsible job and has raised a family successfully, most of the time she is miserable. She looks tense and sad. She is thin, shy, and worried. She’s hesitant to say what’s on her mind, though she is caring and intelligent. She constantly puts herself down. She believes she can’t handle any stress; in fact, she copes very well, but constantly fears that she’s messing up. She has recurrent migraines that force her to bed several times a month. She has to take a medication for these that costs $80 a dose, and her antidepressant medication costs $8 a day. Her family is on a tight budget, and her insurance doesn’t pay for medication, so she feels guilty for having to spend so much money on treatment.
Nancy describes her depression as a well. When it’s at its worst, she is stuck down in the mud at the bottom of the well. The mud is full of worms and rats, and it’s all she can do to keep from being eaten alive. The best she can feel is to be at the top of the well, her elbows perched on the wall, able to see life without truly engaging in it. Most of the time, she’s partway down the well. She remembers what it’s like to feel alive and good, but she can’t quite reach it.
The formal criteria for a diagnosis of major depression include a depressed mood or a loss of interest or pleasure in ordinary activities for at least two weeks, accompanied by at least four of the following symptoms:
I should add that severe anxiety usually accompanies major depression, and it can be difficult to tell which came first.
The symptoms must not be due to the direct effects of medications, drugs, or a physical condition, and must not be a simple grief reaction. The depressed mood is usually self-reported as a feeling of sadness, hopelessness, or discouragement, although it is sometimes denied and may be elicited by a professional interview (the therapist says “You sound sad,” and the patient starts to cry), or inferred from facial expression or body language. Some people emphasize physical complaints or report irritability more than sadness.
The percentage of people estimated to be suffering from major depression at any given time (the “point prevalence”) in Western countries is 2.3 to 3.2 percent for men, 4.5 to 9.3 percent for women. The lifetime risk (the chance that any one person will develop the condition at some point in his or her life) is 7 to 12 percent for men, 20 to 25 percent for women. Risk is not affected by race, education, income, or marital status. The dramatically higher incidence among women raises questions of a gender bias in the diagnosis, since men are generally expected not to complain about feelings of sadness, worthlessness, or hopelessness, a primary criterion for the diagnosis. On the other hand, women may be constitutionally more vulnerable to depression, or simply have more to be depressed about than men. (“Yes, because they have to live with men,” as one of my clients said.)
There is good statistical evidence that recent stress may precipitate the first and/or second bouts of major depression, but that it may take much less stress to set off later episodes. This observation agrees with clinical experience, where it is often easy for patients to pinpoint what made them depressed the first time, but not so easy for subsequent episodes.
Major depression is an acute crisis; dysthymic disorder is a long-term illness. The essential criterion for diagnosis of dysthymia is a depressed mood for most of the day, for more days than not, for at least two years (!). In addition, there must be at least two of the following symptoms while feeling depressed:
Again, excessive worry and fearfulness often accompany dysthymia.
Note that the secondary symptoms are very similar to those for major depression, except that changes in activity level and thoughts of death or suicide are not listed, and low self-esteem is. Clearly the distinction between major depression and dysthymia is rather arbitrary, a matter of degree rather than kind. Yet since the distinction is made, we have researchers testing interventions on one population or the other, with little attention paid to the possibility of error or overlap in the diagnosis. All the newer antidepressants have been tested with major depression, few with dysthymia, because research on dysthymia would be time-consuming and expensive.
Chris fits the picture of dysthymia. A bright, intelligent woman with a forceful manner and a terrific sense of humor, she has been unhappy most of her life. Raised by an alcoholic mother and a critical father, as a child she tried to make them both happy—an impossible task. She rebelled in adolescence, getting in all kinds of trouble. Her first marriage was to a man who was alcoholic and abusive. Having found a lot of strength through Al-Anon, Chris is determined to get her life together. But she and her present husband can’t communicate. Chris is very quick to anger and her husband withdraws. She struggles constantly with her sense of having a grievance against life—she knows this, along with her angry expression, drives people away, but she can’t control herself.
Chris speaks of her depression as a big soft comforter. It’s not really comforting, but it’s safe and familiar. Sometimes she feels as if she’s entitled to be depressed, to quit struggling, to snuggle down and watch old movies and feel sorry for herself.
The point prevalence for dysthymic disorder is estimated at 3 percent, while the lifetime risk is estimated at 6 percent. Again, female gender is associated with higher risk, but race, education, and income are independent.
People with dysthymia are sometimes dismissed as the “worried well,” but nothing could be further from the truth. Imagine spending the better part of two years feeling depressed, having trouble functioning, unable to enjoy life, feeling lousy about yourself, sleeping poorly, and feeling powerless to do anything about it. These people are more accurately described as “walking wounded.” They get through life, but life tends to be nasty, brutish, and short. They are not the Woody Allen stereotype of the self-absorbed neurotic, but rather long-suffering and self-sacrificing.
We often see the effects on children of having a mother who functions like this. Frequently, the children are anxious, tense, and have difficulty getting along with their peers and keeping up with schoolwork. They know all too well that something scary is going on with mom, and they feel that they should be able to do something about it. These children often adapt and become “pseudoadults,” who appear tough and independent. They may actually take care of mom by assuming adult responsibilities—meals, housecleaning, babysitting the younger siblings. Often when mom recovers, there is a backlash. With a functioning mother again, the child is able to feel the anger he has suppressed at having been emotionally abandoned. He becomes rebellious and tests mom to see if she can really be relied on. Mom, still vulnerable, has difficulty understanding why her child isn’t grateful to see her functioning again and may revert to her depressed stance. Depression becomes a vicious circle in the family.
This is a catchall term in the DSM used for all patients who show some symptoms of depression but do not meet the criteria for one of the more restrictive diagnoses. Their symptoms may be less severe, or of shorter duration, or they may meet most of the criteria, but not all, for major depression or dysthymia. This category also includes women suffering from depression associated with the menstrual cycle and people with schizophrenia or other psychotic disorders with an associated depression. But it still excludes people who are grieving, who are depressed as a result of a loss or change in their lives, who are dealing with a medical problem and depressed as a result. In other words, the diagnosis includes a wide variety of people who suffer from depression that has no clear external cause, but is serious enough to interfere with their ability to function.
Estimates are that, at any given time, 11 percent of the population meets the criteria for DDNOS. This is an astounding number, making DDNOS easily the single most common disease in the United States. The combined incidence of major depression, dysthymia, and DDNOS approaches 20 percent at any given time. This does not mean that 20 percent of the population will have depression at some time in their lives, but that 20 percent have it right now. One in five of your friends, family members, coworkers. There is just no other disease (except anxiety) that approaches this kind of prevalence.
If you are now a little confused and can’t see much difference between major depression, dysthymia, and DDNOS, don’t worry about it. These precise distinctions have some use in science, but also have been misused to confuse and scare the public. The bottom line is that with major depression, you feel intensely horrible, confused, listless or agitated, guilty, and suicidal, and your sleep, appetite, and sex life are affected, for a short period of time—at least two weeks. To qualify as dysthymic, you feel some or all of the same symptoms, but not as intensely, for at least two years. DDNOS simply means you feel many of the same symptoms, but not as intensely as in major depression, and not for as long as dysthymia.
Some scientists have pushed the idea that these conditions are separate entities, as if your sniffles might be caused by a cold, an allergy, and a deviated septum. For instance, prominent researchers have advocated for the concept of "double" depression —dysthymia and major depression—giving the idea that there are separate disease processes at work and an individual has been unlucky enough to catch both, rather than simply stating that a person who has been depressed for some time has recently gotten worse. But most patients don’t see these distinctions; they just know they feel bad most of the time, and occasionally they feel absolutely terrible. Most patients know, and an increasing number of researchers and psychiatrists admit, that DDNOS is usually either the early stage of or a slightly milder case of dysthymia, that dysthymia is what people with major depression feel when they get a little better, that major depression is a more severe version of dysthymia, and that whatever it is you have at present, complete recovery is a long way away.
For instance, a study that followed 431 patients for 12 years after a major depressive episode found that they continued to experience major depression, on average, about 15 percent of the time. But that doesn’t mean that they were symptom-free 85 percent of the time. On the contrary, they experienced dysthymia 27 percent of the time and DDNOS 17 percent of the time. The more time they spent in these states, the more likely they were to relapse into major depression.
Bipolar disorder is another type of depression of great concern, and seems to be qualitatively different from major depression, dysthymia, and DDNOS. Bipolar disorder Type I (manic depression) typically features episodes of major depression interspersed with periods of mania. A manic episode must meet the following criteria:
A. A discrete period of abnormal, persistently elevated, expansive, or irritable mood
B. At least three of the following in the same period:
C. Symptoms must be severe enough to cause marked impairment in functioning or place self or others in danger
D. Symptoms must not be caused by schizophrenia or substance abuse
Walt has bipolar disorder. A big man, a truck driver, who seems pleasant and good-natured in his normal state, Walt has had trouble holding down a job for the past few years because of his erratic behavior. Sometimes he becomes sexually obsessed. He can’t get sex off his mind. If an attractive woman is anywhere near, he can’t concentrate on anything but his sexual fantasies. Sometimes he loses touch with reality enough to start believing that she returns his fantasies. When he’s in this state, he’ll spend money he doesn’t have on prostitutes, on gambling junkets, on anything to impress women. He believes he’s attractive, powerful, and charmed, and he feels he can do no wrong. Nothing bothers him. He can stay up for days, talking nonstop. He once showed up at my house, unannounced, to show me his new car—the only time I’ve ever had a client violate a boundary like that. But Walt just wanted to share his joy.
At other times, Walt is severely depressed. He doesn’t believe he’s capable of anything. He hardly has the energy to get out of bed. He tries to go to work, but his lack of confidence makes his employers distrust him. He develops obsessive anxiety symptoms—going back into the house ten times to make sure the coffee pot is unplugged. He’s constantly apologizing for himself.
The mean age of onset for bipolar disorder is the early twenties. It affects men and women equally; it’s reported that over the course of their lifetime, between 0.4 and 1.2 percent of men and women will develop bipolar disorder. At any given time, between 0.1 and 0.6 percent of the population are suffering from an episode. I suspect that the actual incidence of bipolar disorder, or the more severe forms of bipolar II, are really much higher than these formal statistics. There is a high genetic correlation; first-degree relatives of bipolar patients have a 12 percent lifetime incidence, while another 12 percent will experience major depression.
Untreated, a manic episode will last an average of six months, and a major depressive episode eight to ten months; over time, the manic episodes become more frequent. There is a high mortality rate, due to suicide (15 percent of untreated patients), accidental death due to risky behavior, and concurrent illness. Many people with untreated bipolar disorder will die from alcoholism, lung cancer, accidents, or sexually transmitted disease; feeling so invulnerable during an episode, they simply do not take the precautions that most of us have come to accept as part of a sensible lifestyle.
There are other subtypes of bipolar disorder. Bipolar Disorder Type II features episodes of major depression alternating with hypomania (an abnormally elevated or expansive mood that does not interfere with your ability to see reality objectively; “hypo” = “less than” mania). These people make up a distinct subcategory; anyone who can go from the depths of major depression to a giddy, excited, or highly focused and productive state, and do it over and over, is not your usual depressive.
It’s a fairly common story that taking an SSRI or SNRI for the first time may trigger a manic episode. Sometimes, you find a history of bipolar disorder in the family or a pattern of mood swings like hypomania. Other times, the manic episode seems to come out of the blue. Stopping the medication quickly usually resolves the mania. It often seems that bipolar disorder (Type I) is a different kettle of fish from other kinds of depression, because it has such a high degree of genetic loading, the manic episodes are so distinctive and limited to the disease, and the disease itself has such a unique response to a specific medication (lithium) that it makes sense to think of it as primarily a biogenetic disease causing a chemical imbalance in the brain that leads to the unique mood swings.
But the unexplained fact that sometimes taking an SSRI may send a garden-variety depressive off on a full-blown manic episode suggests that there may be more connections than meet the eye. And, I keep running into people who think of themselves as bipolar I who have all the childhood history—emotional neglect, loss, abuse—that goes with major depression or dysthymia. Many clinicians expect that, within the next few years, we will see a breakthrough in understanding the connections in the brain and the genes between mania and depression—and anxiety, ADHD, and PTSD—which may lead to better medications and improved treatment for all.
Adjustment disorder with depressed mood or with anxiety and depression is diagnosed when the depression is clearly a response to an external stress. This is not the same as grief. Grief is a natural response to loss that looks and feels a lot like depression, but people normally recover from grief without formal help. There is also some question of degree. Most people who are grieving are still able to feel that life will go on and hold some future rewards for them, and are able to experience happiness when the occasion merits. They don’t feel decreased self-esteem or irrational guilt. But people with an adjustment disorder with depression are in worse shape than this. They feel hopeless and helpless, empty and joyless. They can point to exactly what made them feel this way—a setback, the death of someone close, an illness, a blow to their self-esteem of some sort—and they don’t yet meet the criteria for dysthymia or major depression. Unfortunately, this diagnosis has almost no predictive value; we can’t tell if you're going to recover next month or if this might be the first episode in a lifelong career of depression. My advice: if you don’t feel like you're getting better within a month after the stress that started you going downhill, or if you're unable to take effective action to remove the stress, consult a therapist.
Some depressions are so severe that the patient begins to experience schizophrenia-like symptoms—hallucinations or delusions, which frequently take the form of an accusatory voice condemning the patient. When depression becomes this severe, it is urgent to get to a good psychiatrist immediately. Treatment is difficult, as most antipsychotic drugs make you feel so sedated and lethargic that you have trouble doing what you need to do to address your depression; and psychotherapy is difficult because you’re not in solid contact with reality. Patience is required.
Before we go on to discuss the last of the forms of depression recognized by the DSM, I want to address a common and dangerous phenomenon that doesn’t have a formal diagnosis. Very frequently, especially in the first one or two episodes of major depression, patients also feel extreme anxiety and panic attacks. As we said, depression and anxiety are closely related, perhaps two aspects of the same stress reaction. But if out-of-control anxiety is not addressed early in the treatment, it often develops into a phobia, or multiple phobias. Phobias have a life of their own and can be very difficult to treat if they get entrenched, so it’s vital to address the panic and anxiety early.
Anyone who has ever had a panic attack knows how terrifying this state is. But the terror can be relieved if patients can learn to understand and control their own reactions. Major depression, when it develops suddenly, feels like an invasion by aliens; you no longer feel like yourself. People who are prone to phobias often experience depression just this way, because they are good at compartmentalizing. The bottom suddenly drops out, and they feel transformed almost overnight into a new person—scared, thoughts racing, pulse pounding, unable to calm down—a panic state. Naturally enough, there is a fear that this unbearable tension will never end. A therapist or psychiatrist at this point has to help the patient regain a sense of control by explaining what’s going on: this is panic and depression. I know it’s horrible but it does end, and you will feel better. It happens to a lot of people. It’s a reaction to stress—and then go on to talk about the patient’s own individual situation, how perhaps it’s really not surprising that he couldn’t take it any more. It can be framed in terms of burnout, which is not a stigmatizing label and suggests that recovery is possible.
The free-floating anxiety that the patient is experiencing can easily attach itself to a specific object or situation: driving; going to work; making phone calls; crowds, heights, enclosed spaces, eating. This is actually a defense mechanism at work, the patient’s mind trying to make the panic more bearable by confining it to a particular situation. But because phobias, once established, can be so difficult to overcome, it’s really best to keep confronting the patient with the situation he fears. Anxiolytic medications (minor tranquilizers) and very small doses of atypical antipsychotics can be a tremendous help at this point, because they can give almost instant relief, while antidepressants and psychotherapy work to gain control of stress. Patients also can be helped greatly by learning relaxation methods like breath control or mindfulness techniques. That flood of stress hormones will respond to repeated practice of relaxation skills. It won’t happen overnight, and the patient is likely to be uncomfortable for a while; but in the long run it’s best not to let the patient be dominated by his fears and depression, and expect him to go on with his normal responsibilities just as much as he can. I have seen too many times the lifelong damage that happens when someone doesn’t get the intense, urgent care that this situation demands.
Many women develop a serious depression after delivery of their child. While the “baby blues” are quite frequent but mild and temporary, postpartum depression (PPD) is a serious complication of pregnancy that happens to almost 15 percent of mothers. PPD includes all the symptoms of major depression—the insomnia, loss of appetite, guilt, self-blame, obsessive thoughts—but this is usually focused on the baby and motherhood. You feel like a bad mother, unable to care for your child; you feel that you don’t love the baby, or it doesn’t love you; you feel that you made a terrible, irrevocable mistake and you’re hopeless about things ever getting better. In the terrible irony of depression, your mental state, if it continues without treatment, may have a real effect on your relationship with your baby. In the worst cases, PPD can become postpartum psychosis, and a new mother may develop delusions like her baby is a child of the devil and must be destroyed.
Fortunately, things rarely get that bad. But being a new mother should be a time of great joy for you, and if it’s not, you should do something about it. If you feel you might have PPD, see a good therapist as soon as possible. Note that I emphasize good. I have seen more examples of damage done by well-meaning therapists, nurses, doctors, La Leche coaches, and other professionals trying to treat new mothers than almost any other group. I think this is because moms are extremely sensitive and vulnerable, and the professionals feel an urgent need to fix the problem before mom and baby are really damaged. So get a good referral, perhaps from your doctor or the pediatric nurses at the hospital, and if you don’t feel a good connection and level of trust soon, shop around some more. You can even ask your therapist: I don’t think this is working for me. Can you recommend someone who is very experienced with PPD?
PPD seems to be another example of stress acting on a vulnerable person. In this case the stress includes both the sudden hormonal changes associated with giving birth (which we still don’t fully understand) and the equally sudden extra work load, lack of sleep, and confinement that new mothers experience. Vulnerabilities include a previous history of depression, trouble in the marriage, and a lack of social support—though again, we all know mothers who have been hit by PPD “out of the blue.” In many cases the depression begins during pregnancy, for some of the same reasons—hormonal changes and stress. Often the pregnancy reveals faults in the marriage that have always been there but become more obvious. Sometimes the husband will have a negative reaction to the pregnancy. Friends and relatives can be jealous or insensitive.
The question of using antidepressants during pregnancy and breastfeeding is unfortunately complex. There is increasing evidence that use of SSRIs, both early and late in pregnancy, is associated with birth defects, primarily cardiovascular. Overall, the increase in risk due to SSRI use is rather small—on the order of two percent compared to one percent among mothers with no SSRIs. But of course, other risks may show up later, as has tended to happen with SSRI research. There are risks to the fetus associated with use of mood stabilizers, as well. So for a depressed and pregnant woman, there is no easy answer. Going off SSRIs can be very difficult, and of course increases the risk of another depressive episode, but there is real reason to be concerned about the effects on the baby. Please refer to Medications for Depression [link]. We have to balance the severity of mother’s depression, and all the effects that can have on a child, against the increased risk of birth defects. If you are severely affected by PPD, consider that sometimes a brief trial of medication can result in a dramatic change.
This remains a controversial diagnosis for people who regularly become depressed in response to changes in daylight or the seasons. The DSM compilers feel enough confidence to say that there are people who become depressed regularly, usually in winter, and recover in the spring, and that this is not related to lack of exercise or opportunity to socialize or to stimulus deprivation, but appears to be related to absence of sunlight. In the depressive phase, patients feel lethargic, sleep too long, gain weight, and crave carbohydrates. They become sad, anxious, irritable, and socially withdrawn. Four times as many women as men are affected; over half the women complain of premenstrual mood problems as well. Symptoms often improve if the patient moves nearer to the equator during winter. Light therapy, using a powerful fluorescent light regularly, was initially thought to be helpful, though later studies show only weak benefits. But sitting quietly in a good light, reading a book or practicing mindfulness, will do anyone some good.
Though most people can recover substantially from an episode of severe depression, they remain more vulnerable to stress and anxiety than others. The advertising for antidepressant medications never tells you the fact that most patients who suffer from depression have poor outcomes in the long run. Clinical trials generally run for two to three months, with "recovery" measured at the end of treatment and little if any follow-up conducted; but this is like arguing that ice is a cure for fever. The STAR*D trial, a huge research program still under way, run by the National Institute of Mental Health instead of a drug company, found that only 30 percent of patients were significantly better after the first phase of treatment. Why such a low number? Because these were real patients in the real world, not paid volunteers carefully screened in a clinical study. We need to be preparing the public and the health insurance industry for the idea that depression is a chronic disease that waxes and wanes over a lifetime, especially if inadequately treated.
Adequate treatment for depression increases the likelihood of complete recovery, but most patients still remain vulnerable. The best predictor of long-term outcome is the duration of the initial episode, from before treatment begins until the patient recovers; thus early detection and effective treatment should be a priority. Recurrence becomes more likely over time; three-quarters of patients can expect to have another episode within five years. The major risk factors for recurrence are psychosocial: the patient's level of anxiety and self-destructive behavior, as well as lack of self-confidence, areas that are much more likely to be improved by psychotherapy than by medication.
It’s important also to emphasize that there is precious little research going on in the U.S about how we can prevent depression, anxiety, or other serious mental illnesses. Research in other parts of the world shows the effects of childhood experience on development of adult depression. In a British study of 1142 children who were followed from birth to age 33, it was found that factors like poor mothering, poor physical care, parental conflict, overcrowding, and social dependence were all highly linked with development of adult depression. Findings like these have been unwelcome in the United States; the emphasis on mental illness as "brain disease" suggests that developmental factors and the social environment are irrelevant. At a recent conference, the director of a major national depression foundation told me she does not believe mental illness can be prevented.
But adult patients persistently come into our offices and tell us that their depression feels as if it's related to past experiences of trauma and deprivation. Do we dismiss that? Are there not ways to help people improve their parenting so that their children will be less vulnerable to depression? Or ways to structure our society so that we all have less chance of becoming depressed?