The following are questions you should be asked at a minimum prior to a diagnosis of depression and treatment.
When Gina told her doctor she was feeling depressed, he gave her a screening test that asked about her symptoms: little interest in doing things, feeling depressed or hopeless, sleep problems, lack of energy, poor appetite or overeating, feelings of failure, problems concentrating, restlessness or slow movements, and thoughts of self-harm. Other than suicidal thoughts, Gina endorsed all of the symptoms and scored high on the test. Her doctor immediately prescribed an anti-depressant.
1) No follow-up questions. A screening test doesn't determine whether someone is depressed or not. The purpose of the test is to determine the possibility of depression. If a person scores high on the test, it is crucial for the doctor to ask follow-up questions and to possibly do other medical tests because a person can have all of these symptoms and not have depression. In fact, as discussed below, there are conditions (called rule-out criteria) that exist indicating a different type of problem could be causing the symptoms. These need to be determined prior to diagnosis.
2) Screening tests don't specify type of depression. Even if a person is depressed, such a test doesn't specify the cause or type of depression. Treatment can vary given the cause of the depressive symptoms. Not all depressions are the same and may respond better to different types of treatment.
3) Screening doesn't determine type of treatment. Anti-depressants are one possible treatment for depression but aren't the best treatment in all cases. If she was having suicidal thoughts, medications may be the best option at the time. But other treatments with fewer side effects can be just as effective and if appropriately selected can be more effective than anti-depressants. Doctors should discuss with their patients the different options.
4) No assessment of functioning. A screening test asking about symptoms doesn't assess how much the symptoms affect a person's life. Again, such a determination helps to prescribe the appropriate treatment.
Much confusion exists regarding depression because the term is used to mean so many different states of being from severe inability to function to everyday sadness. Yet, to treat depression effectively it is necessary to accurately diagnose the condition. If a person is asked, “Are you depressed?” the interpretation of the word “depressed” can influence the response. Using the same words do not always mean the same thing so a diagnosis should be based upon observable facts and information.
The following are questions you should be asked at a minimum prior to a diagnosis of depression and treatment. It may seem like a great deal of information is required but without this information a diagnosis may be inaccurate which could lead to inappropriate, ineffective, or even dangerous or unnecessary treatment.
1) Medical conditions or surgeries.
Certain types of medical conditions can mimic depression such as hypothyroidism. Although the criteria for major depressive disorder (MDD) requires five out of nine symptoms and persistent depressive disorder (PDD) requires two out of six, many of the symptoms can be associated with lack of energy. For instance, if a person has low energy, they are also likely to be indecisive, lack interest in usual activities, may move more slowly, and may feel hopeless as a result. Therefore, the person meets the requirement for the five symptoms even though a medical condition such as hypothyroidism is causing the lack of energy.
Even simple conditions can create such symptoms. I once consulted my doctor because I had most of the symptoms—my husband suggested I do so because he found me sitting on the couch crying because I didn't have the energy to water my plants. Being a psychologist and understanding the diagnostic criteria, I was pretty certain I didn't have depression but I was still concerned depression would be my doctor's quick assessment. However, I should have had more confidence in my selection of physicians. He asked follow-up questions, especially medically-related ones, and determined my symptoms were due to allergies. A few days with an anti-histamine and all my symptoms disappeared.
This example also illustrates why you shouldn't have preconceived notions of what your symptoms are because it is possible to lead your doctor in the wrong direction. If I had said “I think I have depression” rather than “I have no energy” the outcome might have been different.
The same type of symptoms can occur with injuries or surgeries. A surgery can be an assault on the body. So the body's defenses are focused on healing and recovery. When this occurs, the body may have fewer resources available for other activities. This is experienced as fatigue or lack of energy. As stated above, the lack of energy can lead to multiple symptoms and easily be diagnosed as depression. In addition, an injury or surgery can also involve a loss of some type which can lead to a reactive depression as discussed below.
However, the criteria for MDD and PDD state that the symptoms cannot be due to a medical condition. So medical conditions need to be considered prior to any diagnosis and treatment of depression. Unless the symptoms interfere with medical treatment or worsen and develop into a clinical depression, you are unlikely to need anti-depressants.
If you are referred to a mental health professional for depressive symptoms related to a medical condition or surgery, it doesn't mean that you have clinical depression, but that you may need some education related to understanding what is occurring in your body. It is important to explain to the mental health professional that the symptoms are related to a medical condition or surgery. Usually, if the symptoms are caught early, a patient only needs education as to what to expect and ways to help the body heal.
2) Lifestyle changes.
Sudden lifestyle changes can impact the body and cause depressive-type of symptoms. For instance, someone who exercises intensely stops their routine. The exercise produced endorphins (similar to morphine) that can cause withdrawal effects when no longer present in the same quantities. The same can be true of a healthy change such as when a gambler stops the destructive gambling behavior. Diet can also impact the physical system and cause such symptoms especially restrictive diets that are either low on calories or low on other important nutrients.
In my opinion, lifestyle changes are least likely to be part of a mental health assessment. Yet, determining whether any such changes occurred can be critical to an evaluation for depression. For instance, if the change is diet-related, treatment can be as simple as restructuring the diet plan to something more healthy.
3) Use of substances including prescription or over-the-counter medications.
Another rule-out criteria for depression is that it can't be due to a substance. When an individual abuses substances whether it is alcohol, prescription drugs such as pain medication, or street drugs an obvious result can be depressive symptoms especially since some of these substances are in the “depressives” category of drugs. In such cases, however, the symptoms are not considered depression but a reaction to the drugs. Yet, some people may also have clinical depression (and be self-medicating with drugs or alcohol) which can be difficult to determine until the drugs are out of the system.
In addition, even legitimately prescribed and appropriately taken medications can have depressive symptoms as a side effect. A pharmacist can help you evaluate your medications to determine if any could be contributing to such symptoms. If so, a discussion with your doctor can ascertain whether alternative treatments without the undesirable side-effects of the medication may be effective for you.
4) Recent events.
Just about anyone can have depressive symptoms in reaction to recent events or overwhelming life stress. Unless those symptoms, sometimes referred to as reactive depression, become complicated and shift into MDD, they usually are transient or solvable. For instance, distressing events are usually related to some sort of loss and require a period of grieving. The process of getting support and releasing the emotions can help alleviate the depressive symptoms especially in those without a history of clinical depression.
If the issue is stress-related, often a solution to the problem can be found. Symptoms related to stress are usually an indicator of a problem that needs to be addressed. My clinical experience with clients has typically shown that anti-depressants aren't very effective when a person has ongoing stressors. Therapy, however, can help in resolving the issues that are causing the problems. Frequently, the stumbling block is that the solution is not easily seen or may not be desired (e.g. quitting a stressful but high-paying job) but it can alleviate the symptoms.
5) The length and severity of symptoms.
The essential difference between sadness as a mood state and depression is the length of the symptoms. Sadness as an emotion is a transitory state. You may feel sad temporarily or even more consistently for a day or two. However, MDD requires two weeks of significant symptoms to be diagnosed while PDD requires a chronic state of symptoms for a minimum of two years.
Thus, “I feel depressed today” when it is not a persistent state of being is an expression of an emotion, more accurately expressed as “I feel sad today.” Sadness is not a treatable condition but is a normal emotional state. Some individuals, however, may not know how to handle normal emotional states and may require therapy to learn methods to manage emotions. But they do not need medication for emotions.
In addition, the symptoms cause significant distress or impair daily functioning. The greater the interference in daily activities of living, the more severe the depression is considered. Treatment may require multiple approaches the more severe the depressive symptoms (i.e. therapy, medication, hospitalization).
6) Existential or spiritual depression.
A specific type of problem for some (especially creative or analytical types of personalities) that can have associated depressive symptoms are questions about the meaning of life and whether one's life has any purpose. If this question isn't resolved, it can lead to chronic feelings of failure, hopelessness, lack of interest in life and other symptoms of depression similar to PDD. Follow-up questions focused on existential issues are rarely discussed prior to prescribing medications. However, most therapists are trained to ask these questions.
Unfortunately, sometimes people are told by well-intentioned others when they have depression that they just need to have faith in God and the depression will go away. They are told stories about others who were helped through faith. Such stories exist because faith can be beneficial but only when the depression is spiritual in nature. Sadly, if a person has depressive symptoms from other causes such as genetics or medical conditions, they are often made to feel worse about themselves because they feel they are being told their suffering is due to a lack of faith or they believe God has abandoned them.
Due to such dire consequences, spiritual depression should not be assumed. All forms and causes of depression should be assessed before diagnosing spiritual depression as the cause of the symptoms.
An important additional point is a person can have MDD or PDD along with existential or spiritual depression. In such situations psychological and/or medical treatment are required. However, by itself spiritual depression is more of a problem to be resolved and more similar to reactive depression than to MDD or PDD. In those cases, a person may need spiritual counseling or therapy addressing the existential angst.
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Dr. Monica Frank