Why is depression a diagnosable issue?

Question

To me, it seems strange that something such as depression, which anyone can feel at any given time, is diagnosed and treated medically as if it is a mental disorder. I believe depression should be treated with constructive sessions, communication and through giving people a sense of meaning.

Why is depression being treated as if it is a medical problem when it's a problem of thought?

In my opinion, diagnosing a person as being depressed may re-enforce their negative ideas, while the more obvious approach would be to positively re-enforce this person?.

Answer 1

"Depression" is a symptom or state of being, one that everyone can experience.

"Major Depressive Disorder," however, is a diagnosable medical disorder for many reasons. The following list is by no means exhaustive:

• Major Depressive Disorder runs in families, and a genetic component is well established by family and twin studies.
• Anyone who experiences a major depressive episode is at increased risk compared to the general population.
• Major Depressive Disorder costs the US $200 billion per year in medical treatment and workplace costs.
• There are many specific ways in which functioning in the brain is altered in depressed patients. Decreased functioning in the prefrontal cortex (executive functioning) is a good example.
• Contrary to belief common in the 80s and 90s, clinical depression is much more complicated than "a deficiency in serotonin" - the neurology is multifactorial and still poorly understood. However, clinically depressed patients (usually) respond to SSRIs in a manner different from healthy individuals. Prozac is not a "happy pill" if you are not depressed.

"A problem of thought" is one aspect of depression. Most individuals have some combination of cognitive, behavioral, neurochemical, and genetic elements.

I agree with you that telling people "you have a disease" is not always helpful and can be counter-productive in many instances. I too am a fan of positive psychiatry, and I think most individuals could benefit from caring for their mental wellbeing in the same way that healthy people benefit from exercise. On the other side of the coin, it is a serious issue that many patients do not take seriously enough, and non-compliance to medication and therapy is common and can have very serious adverse consequences.

Your question is a good one, and a common one. Thank you for asking. Be aware, though, that it may come off as insensitive and offensive to some who have it bad.

To use rationalist terms: depression and suicide has been a large problem for many people throughout human history. From that, you can assume that 1) many people care very deeply about it, and 2) it is a difficult problem. Given those facts, any statement along the lines of "All it requires is ____", someone will likely take offense.

Answer 2

As @user30133 pointed out,

Not everyone who feels depressed some time [is] diagnosed with depression. Depression is not simply feeling sad. It has specific diagnosis criteria which you can find in [the] DSM

The DSM is the Diagnostic and Statistical Manual of Mental Disorders, of which the most recent edition is the 5th edition (DSM-5) which also links to ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision).

NICE (The UK's National Institute for Health and Care Excellence) states in this 64 page document outlining recognition and management of depression

Depression is a broad and heterogeneous diagnosis. Central to it is depressed mood and/or loss of pleasure in most activities. Severity of the disorder is determined by both the number and severity of symptoms, as well as the degree of functional impairment. A formal diagnosis using the ICD-10 classification system requires at least four out of ten depressive symptoms, whereas the DSM-IV system requires at least five out of nine for a diagnosis of major depression (referred to in this guideline as 'depression'). Symptoms should be present for at least 2 weeks and each symptom should be present at sufficient severity for most of every day. Both diagnostic systems require at least one (DSM-IV) or two (ICD‑10) key symptoms (low mood,^[1] loss of interest and pleasure^[1] or loss of energy^[2]) to be present.

Increasingly, it is recognised that depressive symptoms below the DSM‑IV and ICD‑10 threshold criteria can be distressing and disabling if persistent. Therefore this updated guideline covers 'subthreshold depressive symptoms', which fall below the criteria for major depression, and are defined as at least one key symptom of depression but with insufficient other symptoms and/or functional impairment to meet the criteria for full diagnosis. Symptoms are considered persistent if they continue despite active monitoring and/or low-intensity intervention, or have been present for a considerable time, typically several months. (For a diagnosis of dysthymia, symptoms should be present for at least 2 years^[3].)

It should be noted that classificatory systems are agreed conventions that seek to define different severities of depression in order to guide diagnosis and treatment, and their value is determined by how useful they are in practice. After careful review of the diagnostic criteria and the evidence, the Guideline Development Group decided to adopt DSM-IV criteria for this update rather than ICD-10, which was used in the previous guideline (NICE clinical guideline 23). This is because DSM-IV is used in nearly all the evidence reviewed and it provides definitions for atypical symptoms and seasonal depression. Its definition of severity also makes it less likely that a diagnosis of depression will be based solely on symptom counting. In practical terms, clinicians are not expected to switch to DSM-IV but should be aware that the threshold for mild depression is higher than ICD-10 (five symptoms instead of four) and that degree of functional impairment should be routinely assessed before making a diagnosis. Using DSM-IV enables the guideline to target better the use of specific interventions, such as antidepressants, for more severe degrees of depression.

[1] In both ICD-10 and DSM-IV.

[2] In ICD-10 only.

[3] Both DSM-IV and ICD-10 have the category of dysthymia, which consists of depressive symptoms that are subthreshold for major depression but that persist (by definition for more than 2 years). There appears to be no empirical evidence that dysthymia is distinct from subthreshold depressive symptoms apart from duration of symptoms, and the term 'persistent subthreshold depressive symptoms' is preferred in this guideline.

Answer 3

Short answer
The current understanding is that depression is related to a neurochemical imbalance in the depressed brain. Pharmacological treatment to shift and correct that imbalance may therefore be an effective approach.

Background
Basically you are saying depression is a state of mind and should be treated with counselling rather than tagging a person as mentally ill and medicalizing the care.

As pointed out in the other answers, diagnosis of clinical depression happens through rational guidelines using questionnaires and inventories. Basically, the goal is to extract the clinical, chronic depression from the other group that only shows some, but not all the symptoms of clinical depression. Normal life events can trigger a depression, but that doesn't mean that person needs medical treatment.

In contrast, clinical depression, while being a mental disorder, has correlates in the neurochemical balance in the brain. From a neuroscience perspective, the depressed brain is physically different from a non-depressed brain.

Early medical treatments, and more recent accepted classes of anti-depressants show important correlates to dysfunctional mono-aminergic neurotransmission. A rough timeline of the various anti-depressants shows the neurotransmitter systems that are targeted by these drugs (Ferguson 2001):

• 1950s: MAO inhibitors: elevate monoaminergic (MA) neurotransnmitters levels by blocking their breakdown (serotonin (5HT), noradrenaline (NE) and dopamine (DA) ;
• '50s and '60s: tricyclic anti-depressants: elevate 5HT, NE and DA by inhibiting reuptake;
• '70s: selective serotonin reuptake inhibitors (SSRIs): inhibit specifically reuptake of 5-HT, enhancing those levels of neurotransmitter and not others;
• '70s: NE & DA reuptake inhibitors (NDRIs)
• '80s: atypical antidepressants (a hererogeneous class targeting multiple systems, including 5HT, DA and NE)
• '90's: 5HT & NE reuptake inhibitors (SNRIs)

Without going into their specific mechanisms of action, the point I wish to make is that decades of research in anti-depressants has strongly indicated that a monoamine (MA) neurotransmitter imbalance (most notably 5HT), and specifically a reduced MA neurotransmission is one of the leading factors to a depression (Muñoz & Alamo, 2009). While counseling may help, the underlying disorder may perhaps be treated effectively through treatment with antidepressants.

Regarding your statement that a diagnosis may enforce depressive thoughts - I disagree. Acknowledgement of the depressed state as a serious and debilitating illness is a necessary first step to recovery. Instead of the "oh it's just all between your ears - here are some positive words for you", depressed people are taken seriously and receive the appropriate medical care they deserve. This counts for pharmacological interventions and counseling alike. The first and likely the most crucial stage is acknowledging the problem - for the patient, the care providers, as well as for friends and family.

<sub>References
- Ferguson, Prim Care Companion J Clin Psychiatry (2001); 3(1): 22-7
- Muñoz & Alamo, Curr Pharm Des (2009); 15(14): 1563-86</sub>

Answer 4

Not everyone who feels depressed some time diagnosed with depression. Depression is not simply feeling sad. It has specific diagnosis criteria which you can find in DSM-V. Diagnosis of a mental disorder is needed to help the patient, not to label them or to reenforce any idea. That's why in psychiatry, the term 'diases' is not used. Moreover, with the same way of thinking in your question, none of the psychiatric disorders could be defined. Because psychiatry is based on ways of feelings and thoughts.