1. Depression

2. Learning objectives  Understand the issues surrounding the classification and diagnosis of depression

3. Issues surrounding classification and diagnosis  Depression should not ‘medicalised’  All humans have mood levels.  But mood can be extreme  It is a question of degree  We all experience sadness but mood can sometimes cause serious impairment and functioning.

4.  The symptoms as outlined in the DSM could be experienced by a range of people in unhappy situations or with abnormal personalities.  A minimum of 5 symptoms are required for diagnosis.  Five is a relatively undemanding requirement and  Two different individuals could score their 5 from a completely different set of alternatives.  This means that depression could look very different in two different people.

5.  It can be difficult for clinicians to make the distinction even between  Unipolar and bipolar depression  About 10% diagnosed with major depressive disorder go on to develop bipolar episodes.  Also someone with dysthymic (minor) disorder can have a major depressive episode.  This is called ‘double depression’ and is not uncommon.

6.  Some diagnostic categories have not been validated.  E.g. premenstrual dysphoric disorder are mentioned in the appendix of the DSM-IV to help researchers and clinicians but it remains a controversial area.

7.  Mood has a seasonal variation in normal people.  Seasonal Affective Disorder (SAD) has come to be used for a depressive disorder that occurs only or mainly in the winter.  It remains a controversial area.

8.  Clinicians have recognised other distinctions apart from the formal diagnostic sub-types used in the manuals.  Endogenous (melancholic) depression – arises from internal, biological factors and  Non-endogenous (or reactive) depression – arises from environmental stressors  endogenous depression has more severe symptoms and greater suicide rates. This one responds more positively to ECT and antidepressant medications.  Little conclusive evidence to support the distinction.

9.  Depression in children is included in the diagnostic criteria, but can remain undetected.  Partly because of coexisting disorders involving conduct problems and disruptive behaviour.  Also, irritability is often found in normal young people

10.  When other medical conditions are present such as dementia, cancer, thyroid disorders etc. it is difficult to be sure whether mood disorder symptoms are secondary to this or the side effects of treatment for it, or whether it is the result of a primary mood disorder and unrelated to the medical condition.

11.  Depression frequently occurs alongside other disorders such as substance abuse, alcoholism, eating disorders and schizophrenia.  Anxiety frequently coexists with depression to the extent that a new category has appeared in the DSM – anxiety not otherwise specified – which is a mixture of anxiety/depression symptoms.

12.  Approx 3% of the general population in the UK are treated by their GP for depression.  Approx half the people who go to their GP with symptoms are not recognised as having depression (Holdberg and Huxley, 1992)

13.  Cultural background should be taken into account.  People from non-western cultures often present with more bodily complaints rather than subjective stress (which could be easily misinterpreted)

14.  Depression occurs more frequently in women than in men.  Men may be less likely to admit to symptoms of depression and may be more likely to forget symptoms/  There does seem to be a genuine difference accounted for by psychological and biological attributes of women.

15. KEY POINTS  A number of issues surround the classification and diagnosis of depression. There is overlap with some other disorders and it is also likely that there are different sub-types but not all are seen as valid.  There are slight cultural and gender differences which can get in the way of accurate diagnosis.

16. Summary questions  1. Identify three issues that surround the classification and diagnosis of depression.  5. Depression is a very common disorder and can be quite mild. It is self limiting in that the symptoms usually disappear even if not treated (although they tend to recur at a later point). If this is the case, why do you think that it is important to classify and diagnose the depression?