Thursday, 13 January 2011

Depression's Not Common

Clinical depression's not common, to my mind.

Unhappiness is very common. Unhappiness is an emotion, not an illness.

A little bit of unhappiness, or a lot of it, is a varying intensity of one normal human emotion, so even intense unhappiness is but part of life's rich tapestry and unwelcome though it may be, it's not an illness or a disorder.

Although I'm not a slave to diagnostic checklists, they certainly have a place and shape my thinking. On discussing someone's experiences the details, the nuance, the context, they matter. On considering someone's mental state, eliciting psychopathology and ascribing significance to it/formulating it in other ways and discounting it matters. History taking and mental state examination are clinical activites, not check lists and tick boxes, so there's always room for inclusion of folk and diagnosis of depression for people who don't present with a perfect list for the diagnosis to be textbook.

With this caveat that diagnosis is clinical, contextual and will at times vary from diagnostic lists, I'd concede that most of the time diagnosis falls within accepted frameworks. My training and practice is using the World Health Organisation's International Classification of Diseases, 10th Revision (ICD-10).

It's very useful. It's not just determining what a diagnosis is, it also determines what a diagnosis isn't. For example, "alcoholic" and "alcoholism" aren't in there so aren't and can never be formal diagnostic labels I make. Using the ICD-10 framework engenders a more transparent, consistent, reasoned process to formulation and diagnosis which I find helpful.

Low mood is very very common. Endogenous functional clinical depression arising through abnormal serotin/neurochemistry balance, much less so.

Does this distinction matter?

People with clinical depression have abnormal brain chemistry, this causes illness which has physical and psychological symptoms and signs. By inference, the chemical pathology causing this upset can benefit from chemical solutions (antidepressants). Clinical practice illustrates this, clinically depressed patients do get better on antidepressants.

People may also have low mood because their situation's ghastly and gets them down. If you're down because you're lonely or hungry or in severe chronic pain or you're dying or your loved one's dying or you're abused then is your intense unhappiness clinical depression, caused by chemical illness, so will happiness come in a tablet? Unfortunately not.

People may have low mood through organic syndromes. Stroke damage within the base of the brain or poor blood supply causing ischaemic damage within the diencephalon damages the limbic system, the mood centre in the brain. I've patients who have had cheery dispositions, had stroke damage, are depressed and it's through structural organic brain damage caused by the stroke. Antidepressants have little place.

If unhappiness is sometimes situational and sometimes through structural brain changes, then how do we pick up those unhappy folk who have clinical depression? This matters since such folk with severe clinical depression usually profit from antidepressant drug therapy.

What are the ICD-10 diagnostic criteria?

You need to be depressed for 2 weeks. Being depressed for a few days, then being okay, isn't enough.

You need to be depressed in most situations, most of the time. If you're low for the whole day, but you're okay when your kids visit and take you out to the pub for Sunday lunch, that's not clinical depression. Neurochemistry doesn't rapidly shift as you change from one room to another, so shifting from alone in your house to company in a pub suggests a more reactive/situational cause for unhappiness, or loneliness, rather than being consistent with the chemical illness of clinical depression.

Okay, you've someone with low mood, they've had low mood for 2 weeks, their mood's persistent and pervasive, isn't that just them being unhappy? Yes, it is. To be clinical depression you need to have a number of features :
· Depressed mood that is definitely abnormal for the person, present most of the day, almost every day, largely uninfluenced by circumstances, sustained for at least 2 weeks
· Loss of interest or pleasure in activities
· Decreased energy or increased fatiguability
· Loss of confidence or self esteem
· Unreasonable feelings of self-reproach or excessive and inappropriate guilt
· Recurrent thoughts of death or suicide, or suicidal behaviour
· Diminished ability to think or concentrate
· Changes in psychomotor activity (with agitation or retardation)
· Sleep disturbance
· Change in appetite (decrease or increase) with corresponding weight change

How many of the features correlates with severity :

Mild depressive episode :
"Two or three symptoms are usually present. The patient is usually distressed by these but will probably be able to continue most activities."

Moderate depressive episode :
"Four or more symptoms are usually present. The patient is likely to have great difficulty in continuing with ordinary activities."

Severe depressive episode :
"Eight or more symptoms must be present. Symptoms are marked and distressing, suicidal thoughts and acts are common and a number of ‘somatic’ symptoms are usually present."

The additional somatic symptoms that usually are present would consist of :
· Loss of interest or pleasure in activities
· Reduced emotional response
· Waking in the morning 2 or more hours before the usual time
· Depressed mood is worse in the morning
· Objective evidence of psychomotor retardation or agitation (reported/remarked on by another person)
· Marked loss of appetite
· Weight loss (5% or more of body weight in the last month)
Marked loss of libido

This is important, I believe, because if we diagnose clinical depression when it isn't then people get the wrong treatment. We know from last year's JAMA paper that antidepressants work no better than placebo in mild, moderate or severe depression and only are shown to work better than placebo in very severe depression. We know from a paper in this month's British Journal of Psychiatry that, still, antidepressants don't work in mild depression. Okay okay, studies show us averages and trends, individual patients may respond brilliantly to antidepressants despite have mild or moderate depression, but on average response is the same with antidepressant or placebo.

If we need 2, 4 or 8 core features of depression, and typically there're also some of the 7 somatic features of depression, to my mind that's getting to a much more specific (and smaller) group than all people who have intense low mood.

It's also a harder way to work. If we equate intense low mood with depression, so refer for psychological therapy and start an antidepressant, then everything's done and is easy. If we're sleuthing out who has a depression that's reactive/situational, who has a depression that's organic/structural and who has a depression that's endogenous/chemical, that's a more involved assessment. Worse, if only the last group generally profit from an antidepressant, we're then having to help people with ghastly low mood, suicidality and feelings of not coping through support that doesn't typically include antidepressants. We have to do more than just offer a prescription and refer to a psytchologist.

Harder work, both in assessment and interventions, but to my mind increasingly it's looking untenable to work in any other way.


bunapa said...

Agreed. An SSRI prescription and referral to counselling/CBT is an easy way out for GPs seeing the unhappy, especially in a 10 minute consultation.

I don't get it right all the time.

We used to have a very good and prompt counselling service with no waiting list upstairs in our surgery. But then the contract was put out to tender and things changed for the worse.

So, we generally avoid SSRI on first contact which takes care of the 'unhappy for less than 2 weeks' group.

We try and complete PHQ-9 and GAD-7 as well as looking for the obvious body language and visual signs.

For example, if someone turns up to their appointment on time, well-groomed and smiling appropriately I am not too worried.

However, I did see a lady in her 30s this morning who had started her sisters' Sertraline 3 weeks ago and was adamant she felt better on it!

I forgot to ask how her sister felt.

Clinical depression is more easy to diagnose retrospectively so I sometimes readcode Low Mood and am happy to alter this at a later date if it becomes more obvious the person has developed Clinical Depression.


Alison Cummins said...

You left out checking to see if the person has one of the bipolar spectrum disorders. (Cyclothymia through Bipolar I.) In this case they might have reactive depression (be suicidal when alone and perk right up when someone compassionate shows up); gain, rather than lose weight; and not have much of a "normal" or "usual" to compare to.

These folks can be in deep trouble (I know, I'm one) but if you dismiss them as "reactive" instead of recognizing them as "atypical" then you won't be able to help them.

Another problem when comparing to "normal," especially if you are looking for changes from two to six weeks ago, is what if the person has been depressed for a long time? Checklists specify a timeframe (How has your libido changed in the last two weeks? Six weeks? Six months?) and if it hasn't changed in that period then the person is deemed "well." I filled out several of those and was pronounced "well" and therapists were very confused and wished to know why I considered myself depressed. No change in libido in six months, and responsive in interview. Well, my partner and I hadn't had sex in four years and I didn't miss it. But before that I had been quite randy. (By that time hypomania for me had deteriorated into being extremely irritable, not expansive, optimistic and productive.)

You need to be looking for the bipolar spectrum types not just so that you don't miss them but so that you treat them appropriately. Antidepressants alone can provoke [hypo]mania.

Alison Cummins said...

Checklists like the ones you are discussing interfered with my getting appropriate help for years; I eventually refused to fill them out or respond to people reciting them except by weeping tears of hopelessness. (It turned out that weeping will suggest to an interviewer that something is wrong even if you won't cooperate with their checklist.)

The folks who identified that I was depressed or bipolar II didn't use checklists; they used open-ended questions. (In one case that was a PhD psychologist; in another it was a psychiatrist.)

Now I have a label. My helpful psychiatrist has retired, but going forward I can say "bipolar II, diagnosed by a psychiatrist, treated with sertraline and lamotrigine and keeping a well-paid job for twelve years" and I fervently hope I will never have to respond to a checklist again.

pj said...

Strictly speaking we don't know that 'endogenous' severe depression is due to a 'chemical imbalance'. We often tell people that but the evidence is equivocal to negative in strength.

Milk and Two Sugars said...

This is a lovely post. You've described the subtlties, and the importance of those subtlties, so eloquently. All illness exists along a spectrum, doesn't it?

butterflywings said...

I agree with Alison Cummins about the problems with checklists.
I also don't buy the distinction between 'endogeneous' and 'reactive' depression. The brain rewires itself in response to the environment - a miserable situation literally our alters brain chemistry. Genetically some people are more vulnerable to this than others, of course. And someone who is becoming depressed is more likely to end up in miserable situations, worsening the depression. You can't really untangle nurture and nature so easily.

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The Secret Life of a Manic Depressive said...

Do you consider bipolar depression to be a clinical type of depression? I've always found it exceptionally hard to explain how I can be depressed no matter what is happening. My boyfriend has told me that if I suffer a depressive episode near/on our wedding day, we should cancel it, because the day will not make me smile.

I've always had trouble with it because I don't present "typically". I don't move when I'm depressed, and I don't suffer from insomnia- I sleep for about 15 hours a day instead. I think of them as the polar opposites to my manic episodes. That's a kind of comforting thought, in a way. My worst episodes have been after a hypo/mania. It's like my brain's trying to correct the balance but going a bit too far.

Babbler said...

and even if you refer frequent attenders who have s*it life syndrome to the psychologist, there isnt a lot that we can do in 12 sessions-

they don't fit any of the frameworks for IAPT, consume massive resources at at the top of the stepped care model (psychologist/psychotherapist),and all the while we're looking for other services to sort out housing, benefits and the like because those social issues take up most of our sessions with the client