A depression diagnosis usually marks a turning point in your experience of the illness. Up to that point, you may have downplayed the seriousness of mood problems, or you may have been less aware of feelings and focused instead on pain or insomnia or some other physical symptom.
When things get so bad that you can’t lead the life you’re used to, then you know you need help but may still have no idea what the cause is. So you head for the doctor’s office – whether it’s your primary care physician or a psychiatrist – and hope they’ll be able to tell you what’s wrong and do something about it.
You want a diagnosis and effective treatment, but there turns out to be a lot of disagreement about both. In this post, I’ll discuss the problems of screening and diagnosis and the frequent contrast between formal guidelines and the pressured results of a typical 15-minute visit to a doctor’s office.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the authoritative publication of the American Psychiatric Association. It presents the formal criteria for the classification and diagnosis of all forms of depression. The well-known list of symptoms may be loose and too limited, but they are the defining characteristics that every diagnosis is supposed to take into account.
First, you need to feel despair most of the time or feel little interest in anything. If you have one of those two, you then need to have at least five more symptoms out of a list of seven. Those are: feelings of worthlessness, inability to concentrate, loss of energy, changes in appetite, sleep problems, irritability and slowed-down speech or movement.
Screening for Depression
The first step might be a screening test to gauge your condition. There are many questionnaires of differing length and complexity, some of which are designed specifically for certain age groups. All of them are based on the DSM criteria.
A doctor might have you fill one out on the spot, or you might have tried one of the tests commonly available online before seeing a physician. It could be helpful to do that since primary care doctors miss as many as half the cases of depression. If you go in prepared, either with screening results or a record from your own tracking of symptoms, a doctor can’t overlook depression as the possible cause.
These tests are often used as part of a diagnosis, but the results of a questionnaire are only a starting point. Screening is supposed to be used as an indicator, not as a diagnosis. If you or a doctor stop take screening as the final word – and that does happen – then the diagnosis misses the particular nature of your experience of depression.
It’s the problem of focusing only on the illness, not on the person. That’s the basis for some of the criticisms of the diagnostic process as a whole. More on that later.
The DSM spells out a careful procedure for differentiating one mood disorder to be sure that depression is the right target. It also has detailed discussions of the diagnostic procedure for each type of depression, including both a major depressive episode and major depressive disorder.
The detailed guidance of the DSM is intended primarily for psychiatrists, but the basic criteria are used universally.
There’s an odd fact, however, about the DSM procedures. In practice, psychiatrists don’t always use them. One survey, for example, found that about 25% did not apply the DSM criteria. While that study didn’t probe the reasons for not using the DSM, there are several criticisms of the diagnostic process that could play a role. It’s helpful to understand them if you’re about to meet with a psychiatrist for the first time.
Diagnosing the Person, Not the Disorder
In a blog post at Psychiatric Times, Dr. James Phillips wrote that the patient is a missing person in the DSM. It’s fine for researchers to study major depressive disorder or dysthymia, but a psychiatrist has to treat Mr. or Ms. Jones’ depression.
He compared identifying a person by a disorder to fitting them with a cheap suit off the bargain basement rack. It doesn’t fit well because one individual’s depression is not quite like another’s.
His advice to fellow psychiatrists is to forget about the DSM as the primary guide for assessing a patient. He suggests using it as a “crude guideline” that puts you in the right ballpark. The diagnostic label should be only the beginning of the process of deciding on treatment.
I like that approach, and it corresponds to my experience in working with psychiatrists. Perhaps I’ve been especially fortunate, but the psychiatrists I’ve seen, except for one, have not only given me plenty of time to discuss my version of depression, they’ve never even bothered to talk to me about a DSM diagnosis.
The one exception, however, seems to be more typical of recent changes in the profession. I had 15-minutes with him, and he cut me off when I tried to give him some background on my illness. “This isn’t therapy,” he said curtly. “This is medication management.” That was that.
Even when a visit isn’t that extreme, I’ve heard from many who live with depression about psychiatrists who stop after checking off the standard symptoms and promptly send you off with a prescription. All in that 15-minute session. End of story – except for medication management, which is often the only form of follow-up. Seeing a person only as a disorder fitting a standard description is becoming more common.
Diagnosis in Primary Care
While there is growing pressure on psychiatrists to limit the time they spend with patients, the time pressure on primary care physicians (PCP’s) is even greater. Yet it is these physicians who make most of the assessments for depression. That’s partly the result of insurance company policies that make the PCP the gateway to all referrals for specialized care. Another factor is that many patients with depression only complain of physical symptoms and wouldn’t think of seeking out mental health care.
A general practitioner may also lack experience – and sometimes personal comfort – in dealing with emotional and behavioral issues. That works against the sort of open discussion about how the patient’s life is going that could flag depression. Even if a physician wants to open the door to more personal discussion, that takes time – and there isn’t much time.
Make It Fast
Most primary care doctors have only a few minutes to sort through a patient’s description of symptoms and decide what to do. That’s one reason they often rely on screening tools and interview protocols that can be completed in just a few minutes.
According to the US Department of Health and Human Services’ Healthy People report of 2010, the rating scales are about equally effective. Asking 2 simple questions about mood and anhedonia (“Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”) may be as effective as using the published rate scales. That really cuts it down.
Even though all the rating scales relate back to DSM criteria, most non-psychiatrist physicians don’t use the DSM diagnostic procedure to assess depression. The same survey study that indicated 25% of psychiatrists use DSM less than half the time also found that more than two-thirds of non-psychiatrists usually do not use it.
As a result of all the pressures of practice and the inherent difficulty of detecting a mental disorder, it’s easy to see why so many cases of depression are not recognized.
What To Do
There are many recommendations for improving diagnosis and treatment of depression in primary care. Like the critique of DSM by James Phillips, many emphasize the importance of putting the person at the center of the process.
As one writer put it, the role of the primary care physician is changing. Under the old paradigm, a doctor took care of sick people. The new paradigm sees the role of the doctor as keeping people well. This new role calls for a sensitivity to the whole person that doesn’t seem to be featured in the medical curriculum. So the change is difficult.
Those of us looking for help with depression want to be treated as individuals and want a physician, whether a psychiatrist or not, who can spend time to understand what we’re going through.
What has your experience been with the diagnostic process?