The Frontal Cortex

Is Depression Overdiagnosed?

A recent study in The Archives of General Psychiatry suggests that 25 percent of all Americans diagnosed with depression are actually just dealing with the normal disappointments of life, like divorce or the loss of a job. Their sadness is being treated like a medical condition. They were given drugs, when what they really needed was support:

The study also suggested that drug treatment may often be inappropriate for people who are experiencing painful — but normal — responses to life’s stresses. Supportive therapy, on the other hand, may be useful — and may keep someone who has been through a divorce or has lost a job from going on to develop full-blown depression.

Obviously, it’s tough to know where sadness ends and clinical depression begins. And nobody wants to return to the days when society stigmatized depression and pretended like it didn’t exist. But until we have a biological marker of depression – or something more conclusive than a vague checklist of symptoms – shouldn’t we err on the side of restraint? Shouldn’t psychiatrists seek to avoid medicalizing sadness? When confronted with a borderline case – the patient might be sad or they might be depressed – why not try supportive therapy or cognitive behavioral therapy first, before getting that prescription for Prozac? Sadness sucks, but it also serves a purpose.

Comments

  1. #1 Matt Penfold
    April 3, 2007

    When it comes to depression following bereavement there are guidelines in the UK. I am not sure if similar guidlines apply elsewhere. In the UK the guidelines for diagnosing depression following bereavement indicate that at least three months should have passed with no improvement in mood. Of course after three months most people will still feel the loss of a loved one accutely but they will have begun to start to function normally on a day to day level. I suspect that many doctors would also take similar view with other life impacting events, although the time scales involved may vary.

  2. #2 MattXIV
    April 3, 2007

    But given that SSRIs are relatively cheap and have unpleasant but not seriously harmful side effects and that they’re about even with efficacy with CBT if I recall correctly, why not use them as the first line? CBT is expensive compared to meds, so it makes sense to save it for those who need the full force of meds and therapy combined.

    Not to mention that “healthy” Americans taking an interest in tinkering with their serotonin systems is hardly unprecedented (MDMA, LSD, psilocin, etc). SSRIs probably aren’t going to do that much for people who don’t have clinical depression or an anxiety disorder, but the desire to change one’s mind chemically is not restricted to those who fit neatly into DSM-specified categories or want to see elaborate geometric patterns in their mind’s eye.

  3. #3 joltvolta
    April 3, 2007

    Like many mood disorders, the point when symptoms become an indication of a disorder is when it impairs the individuals ability to function for a length of time. Unable to goto work. Social communication impaired, relationships strained, unable to hit up the store, etc. The daily events become too difficult to accomplish.

    I’m wondering how many people are perscribed medication to treat depression that are general family practicions or have little experiance with recognizing depression.

  4. #4 writerdd
    April 3, 2007

    I’ve been sad and clinically depressed and for me, at least, the two feel nothing whatsoever alike.

  5. #5 Roger
    April 3, 2007

    I go back and forth on this issue. I want depression treated as soon as possible – having gone through it myself I know how difficult it is – yet medicating people just to get rid of normal sadness is also wrong. Certainly the initial part of my depression during a period of grief, but it did go further and where the line was crossed betwen grief and depression is hard to say.

    P.S. The depression was a response to the death of my mother, when I was driving, to a funeral, of the uncle after whom I was named. And so I’m not sure any dividing line will ever be clear between grief and depression.

  6. #6 Joseph j7uy5
    April 3, 2007

    I don’t see how anyone can say whether it is right or wrong; what matters is whether the patient is adequately informed about the rationale for the prescription, the potential risks and benefits, and the probability of success vs. the probability of unacceptable adverse effects. If the patient is well informed and everyone is acting in good faith, there really is no place for anyone to make a value judgment about a private transaction between two individuals.

    Having said that, I will add that there are studies indicating that it is the symptom profile of the patient, not the presence or absence of an antecedent stressor, that predicts the probability of a positive medication response.

    As for time frames, the rule of thumb I tend to use is to give someone about 8 weeks to see if they start to come out of it without medication, but that is a very rough guideline. If someone has a history of prior episodes of depression that did respond to medication, or if the symptoms are unusually severe, then I would tend to move quicker. If someone has demonstrated a good capacity to rebound from loss, and has good supports, and is generally in good shape other than the grief, I might wait longer.

  7. #7 BBomb
    April 4, 2007

    You wouldn’t say this if you were one of the clinically depressed people living a life of bleakness. It is uncertain that a depressed person will reach out too often for help, especially if they are told what they are feeling is “normal”.

    Antidepersents do not make sad people happy, they have no effect on a normal brain. One of a doctors most helpful diagnostic tool right now is to perscribe drugs and then see what works.

    I hate people that think they are doing society a favor by getting imbatween a doctor and their people.

  8. #8 therap-E
    April 4, 2007

    The DSM was written by psychiatrists, not psychologists. If psychiatrists want to medicate sadness, that is their perogative. Psychologists can’t medicate anything. Maybe we need our own DSM.

  9. #9 Alvaro
    April 6, 2007

    “One of a doctors most helpful diagnostic tool right now is to perscribe drugs and then see what works.”

    “But given that SSRIs are relatively cheap and have unpleasant but not seriously harmful side effects and that they’re about even with efficacy with CBT if I recall correctly, why not use them as the first line?”

    and this among people reading this blog.

    Sounds like voodoo medicine. Fascinating-and sad. Maybe an epidemic of frontal lobe dysfunction?

    no magic pill to cure that?

  10. #10 Caledonian
    April 17, 2007

    You seem to be assuming that depression is actually a distinct and physiological problem.

    Until you find physiological markers, how about you avoid characterizing mental states as organic diseases?

  11. #11 J
    June 21, 2009

    Since no one has posted in nearly two years, this may not be read. I would just like to agree STRONGLY with writerdd’s comment, “I’ve been sad and clinically depressed and for me, at least, the two feel nothing whatsoever alike.”

    I’ve lived with clinical depression for nearly 70 years. Although sadness and clinical depression certainly share symptoms, there is an underlying sense that the sadness will end. Clinical depression is a bottomless black hole with slippery sides and absolutely no hope of escape.

    My opinion only — comparing clinical depression to the “normal” depression of sadness related to life events is like comparing a mild headache with the world’s worst migraine. Two different animals, truly.

  12. #12 Aida Mehonic
    August 20, 2009

    There’s a book on depression by a famous molecular biologist Lewis Wolpert, called Malignant Sadness. He puts forward an analogy with cancer, so that sadness to depression is like normal cell growth to tumours.