Major Depressive Disorder or Normal Sadness?
Nov 24, 08- (by Jason Schwartz)
- 9 responses
- Controversy Alley, Sober Salon
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An important question in the new issue of Psychiatric Times:
A diagnosis of MDD is warranted, according to DSM, when a patient has at least 5 of 9 specified symptoms for at least 2 weeks, and the 5 symptoms include either depressed mood or an inability to derive pleasure from life. The sole exception is that bereaved patients are not considered to have a disorder if they otherwise meet the criteria, as long as their symptoms are not unusually severe and last no longer than 2 months. The reason for the bereavement exclusion seems obvious: people who respond to the loss of an intimate with intense sadness, sleep and appetite difficulties, a loss of concentration on usual roles, and the like, do not have a mental disorder. Rather, they are responding normally to a situation of intense loss. The distinction between sadness that is a normal result of painful losses and depressive disorder is a fundamental one that has been explicitly recognized throughout the 2500-year history of psychiatric medicine.
Yet, the bereavement exclusion raises the question of whether people with enough symptoms to meet the MDD criteria—after, for example, the unexpected loss of a valued job, the collapse of a marriage, the failure to achieve a highly valued goal, or the diagnosis of a life-threatening illness in oneself or a loved one—are similarly reacting normally to situations of intense loss. For thousands of years, until DSM-III, physicians understood that these kinds of situational contexts were an important consideration in determining whether someone was experiencing normal—although intensely distressing—sadness or a depressive disorder in which something has gone wrong with mood processes and the sadness symptoms are no longer linked to the situation or likely to remit over time. Unlike many other diagnoses in DSM, which contain qualifiers that require symptoms to be “excessive” or “unreasonable,” no such qualifiers exist for MDD. Aside from the bereavement exclusion, the diagnostic criteria do not take into account the context in which symptoms arise.
Ample scientific evidence—ranging from infant and primate studies to cross-cultural studies of emotion—suggests that intense sadness in response to a variety of situations is a normal, biologically designed human response. Recent epidemiological analysis suggests that the consequences of stressors can be either normal or abnormal, similar to those for bereavement.1 In its quest for reliability via symptom-based definitions that minimized concern with the context in which the symptoms appeared, DSM unintentionally abandoned the well-recognized, scientifically supported, indeed commonsensical distinction between normal sadness and depressive disorder.
Along these lines, what about an addict who burns their life to the ground in their addiction? Even the exclusionary criteria are limited to physiological effects of drugs. In many cases, are depressive symptoms in the face of a life ravaged by addiction not a sign of intact reality testing, an indication of some strengths?
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It’s those other symptoms, honest, that make the diagnosis. The loss of appetite (or gain), the insomnia (or hypersomnia), and the loss of libido. The basic weight that weighs a person down, makes concentration impossible. Will loss of anything valuable add to the onset of these symptoms? No question. Most of us really are differentiating between an adjustment disorder with depression (something that will resolve within 6 months, therapy or no) and a major affective disorder, which presents in different ways for different affective disorders, Depressive, only one of them.
Good point. Those vegetative symptoms are also the first to improve when someone enters recovery.
I wonder though, why do we call something that is part of the bio-psycho-social healing process, for so many people, a disorder at all?
Because it is a disorder. Depression is not normal. FEELING DEPRESSED is normal. Depressed is a feeling. DEPRESSION is an illness. I have depression, I am NOT depressed. (check out http://depressionmarathon.blogspot.com for more on that discussion) I refer to my depression as a brain disease or my invisible brain tumor. A brain tumor in the right spot might cause all the same symptoms of the depression I currently have. If people could see depression on an x-ray, they wouldn’t question it’s validity. If people could live in my shoes for one day, they wouldn’t refer to an illness as a normal part of healing or of life.
There are situational depressions which can be linked to specific life events. The resolution of situational depression may be greatly helped by the passage of time or the resolution of the life stressor.
Then there is Depression–the ILLNESS, which may (or may not) come out of the blue, mine came out of nowhere without warning; which may not be connected to a significant life event or stressor, my life was “perfect” at the time; and which is also not linked to drug or alcohol abuse, I wasn’t using at all at the time or for years prior. My alcoholism developed when I began using alcohol to cope with increasingly debilitating depression.
Feel free to check out my blog, mentioned above, for more stories and comments from others battling mental ILLNESS.
This post was NOT meant, in any way, to suggest that depression is not real or that depression is not a disorder. (I didn’t explicitly say it, but I don’t think that I suggested otherwise.) I don’t question its validity in any way. Rather, the post was about sadness and grief being pathologized. In particular, I was referring to depressive symptoms in early recovery being too quickly diagnosed as Major Depressive Disorder (usually assumed to be chronic). I see this happening in very large numbers. Most addicts and alcoholics entering treatment report depressive symptoms and many meet diagnostic criteria for MDD. However, for most, these symptoms improve significantly in the first 2 to 6 weeks of recovery. (Coincidentally, the same time frame we’d look for a response to an SSRI.) Many of these people have a lot to be profoundly sad about. Why are clinicians so aggressive in diagnosing them? (It’s not just addicts. I’ve seen at least 3 family members diagnosed and treated with meds for depression within a couple of weeks of the death of a spouse or child.)
It makes a lot more sense to be more aggressive with people whose symptoms do not improve, whose symptoms worsen, who are at risk for self-harm, have a strong family history, have an onset pattern that suggests and independent disorder, or whose symptoms are so severe that they have difficulty participating in treatment or recovery.
I wish you nothing but the best, particularly as someone who has been hospitalized for depression and found it crippling. My experience with it was secondary to my addiction, but it got so severe that it did not remit with recovery and required psychiatric help. It took a good 18 month to really improve and while I’m grateful for the psychiatric help I received, I’ve since had to wrestle with their assumptions that it was a primary and chronic condition.
Again, no doubts about the validity of the illness or that primary depressive illness can co-occur with addiction.
Thank you for clarifying your comments, Jason. My reaction is based on the pervasive stigma and misinformation surrounding mental illness. This stigma leads to mistreatment of individuals with mental illness by everyone from family to employers to our own government (www.thesecondroad.org/tsr/2008/07/10/medicare-reform-passes/, http://www.thesecondroad.org/tsr/2008/08/08/alcoholic-okay-mentally-ill-not-so-much/, http://www.thesecondroad.org/tsr/2008/08/11/ugh/).
But worse, and what most concerns me, is the stigma discourages people from seeking treatment. Stigma makes people question the reality and validity of the condition. And stigma keeps people from taking medications for an illness they either don’t believe they have or don’t believe in at all.
Those beliefs and that stigma keep people from being treated, and UNTREATED depression is the number ONE cause of suicide. The vast majority of people who complete suicide do NOT do it because they are bereaved, or because their boyfriend broke-up with them, or because they lost their job. No. Untreated depression is the number one cause of suicide. People die because we’ve made mental illness into a moral and/or character issue rather than a biological health issue. That’s why this is important to me.
If you will allow, I would like to gently challenge some of what you wrote above. You logically state that it makes sense to be more aggressive with people who have treatment-resistant depression. I understand this as: don’t diagnose or treat people with meds until we’ve given them some period of recuperation, perhaps after a major stressor? Okay, but do you see the stigma there?
What is wrong with being diagnosed with depression? (Nothing, except the stigma of being weak, lazy, crazy, etc…) And why not treat it early? As with addiction, isn’t earlier intervention better than later? If, after the death of their spouse, a person began overeating and developed Type 2 Diabetes, should we not offer assistance until after they begin losing their eye-sight?
And what is wrong with taking medication for a debilitating condition? Anti-depressants aren’t happy pills and they certainly aren’t addictive. But if we think of depression as something normal, or something we should be able to “get over,” then the resistance to medications makes sense.
It is for this reason that I focus on depression–the illness. People are willing to take meds for other illnesses and conditions because they can see the spot on the x-ray or the abnormal lab results. That spot and those lab results take the person’s character out of the equation. Meds, therefore, become okay. It’s an abnormal condition, an illness, and the patient had nothing to do with it!
Lastly, and then I’ll step down…
Again, gently, why have you had to “wrestle with their assumptions that it was a primary chronic condition?” If you received treatment, and you got better, does it matter?? And if so, why does it matter? Think about it.
Thanks for the discussion, Jason.
Help Comment Admin!! I wrote a lengthy comment back to Jason last night regarding this post, but it hasn’t shown up and it won’t let me duplicate it!
It is cleared now. For some reason it was in the spam filter.
I suspect that you and I will have to agree to disagree.
First, I don’t think conservative diagnostic practices have to be any more stigmatizing than being cautious about limiting antibiotic use to bacterial infections and not viral infections. Second, I think that when facing major life stressors, profound sadness or anxiety is part of being human and not an indication that something is wrong and that we should not treat them as though something is wrong until something is wrong. In the context of admitting people to addiction treatment, most clients find it reassuring to learn that sleep disturbance, mood instability, stress sensitivity, sadness, guilt, anxiety, etc., are pretty common and that for most people these symptoms will improve significantly in the coming weeks. We also talk about what’s not normal in early recovery and would require a visit with the psychiatrist, suicidal thoughts, inability to get out of bed, their symptoms getting worse rather than better, etc. Knowing this does nothing to decrease their symptoms, but, for most of them, knowing that it’s common, that there is a fairly predictable course to it, does decrease their suffering from those symptoms.
In the same vein, in the field of addiction treatment, there is a history of overdiagnosis of addiction. Every kid who’s mom found a bag of weed in their sock drawer was diagnosed as substance dependent and sent away to a 28 day stint in treatment. It was harmful for several reasons: some of these kids and their family took on an identity based on having the illness of addiction when, in many cases, they did not; on the part of the treatment professional, it represented poor use of their fiduciary responsibility which came back to bite them and us in the form of high copays, reduced coverage and barriers to accessing treatment; this practice, coupled with the application of addiction to every compulsive behavior had the effect of watering down the meaning of addiction and actually increasing stigma; this overdiagnosis also deservedly resulted in a loss of trust for addiction professionals.
As for my own case, getting the right diagnosis is important to me. I had a sense, based on the onset and course that it was secondary to my addiction and not chronic. The assertions that it was chronic, periodic relapses were likely and that continuous treatment was necessary didn’t sit well intellectually or in my gut. It also led their attention to the problem that I believed was secondary. They were not doing a good job taking account of the person-in-environment, their approach wasn’t very holistic. I had to become noncompliant to find out. It’s been 18 years and no problems. Having a chronic illness, whatever it is. Major life changes require more caution and footwork in the context of a chronic illness–will this change precipitate a relapse?; should I not take a position that requires a lot of travel?; should I line up a psychiatrist before I move?; if I stop exercising will that cause a relapse?; will I pass this along to my kids?; do I have enough of my meds to last through my vacation?
It can go on and on. Most are small sacrifices if you really have the condition, but silly to subject oneself to if it was acute and situational rather than a chronic condition.
I had a similar experience with a chronic cough. It was awful. It interfered with sleep and people knew I was coming a mile away. I got diagnosed with asthma put on a regimen of medication and some behavior changes (All of the sudden, treating my allergies became important. Meds, hypoallergenic pillow cases, etc.) I spent a year going round with the doctor and specialists. The cough improved, but didn’t go away completely and I kept telling them that it felt like the real problem was in my throat, not my lungs and that it was a maddening itch. They insisted the itch was secondary to the coughing. This went on for a year and I finally saw a specialist who determined that the problem is that my pharynx is susceptible to inflammation and that it doesn’t heal on it’s own after a cold. I took a non mood-altering cough suppressant for 2 weeks to allow my pharynx to heal and the cough went away.
There would not have been any major life implications for treating my incorrectly diagnosed asthma. There’s nothing wrong with having asthma, but something rubs me the wrong way about spending 50 years treating a condition that I don’t have, thinking of myself as an asthmatic when I’m not (I’m really a pharynx-itis-er!), and never diagnosing the real problem. Giving me a diagnosis that came with a treatment regimen and sending me on my way met his need very well and did a poor job of meeting my needs. That psychiatrist asserting that my depression a chronic condition was offering something that served his narrative of mental illness as overwhelmingly a chronic illness that requires long term psychiatric care, but it wasn’t true. I’m convinced, that in my case, subordinating my judgment to his could have done some harm.
Hey Jason! Yes, there probably are things we will continue to disagree about but not everything.
I tend to bristle when people question a depression diagnoses for all the reasons I stated above, as that has been my experience both as a person with mental illness and as a mental and physical healthcare provider.
When people find out I have depression, they want to talk. I spend much of my time convincing them to find a doctor they can work collaboratively with and stating,”Yes, it is a biological condition, and it can be treated!” It is another stereotype of this illness that one needs to “be on medication forever.” That’s not true, but that’s what many believe.
As for your case, it sounds like you had a lazy or negligent psychiatrist. There are some of those out there, but most know that depression comes in multiple forms. Even with my severe, long-standing, treatment-resistant depression, OUR (my shrink and I) goal is to get me down to as few meds as possible or off meds totally. My brother had depression for about six months. He’s fine now.
That’s sort of my point. Depression is TREATABLE. It can be cured, like some forms of diabetes, or it can be managed long-term, like other forms of diabetes.
So I think we are actually not too far apart here. Every patient, regardless of the diagnosis, needs to take responsibility for his/her own care, and that includes finding a doctor one can work collaboratively with and express his/her opinions to. I commend you for doing just that.
Unfortunately, many people question the diagnosis, disregard doctor’s orders, or won’t even seek treatment because of the stigma. They don’t “think” they have depression because they don’t want to have depression. I know. I was there. Just like my addiction, I had to accept the illness first before I could begin healing.
Lastly, I agree people in grief or recovering from a huge life stressor should not necessarily be diagnosed or treated with meds for depression. At the same time, if getting the diagnosis actually RELIEVES their worries about all the same symptoms you highlighted, or taking medications shortens their suffering (or even stops it from becoming a chronic condition), what is the harm with that?
Thanks again for the discussion!