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 depression 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.
DSM Criteria
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.
Diagnostic Procedure
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?
Image by digitalpimp at Flickr.
I have read your article “When a Depressed Partner Falls Out of Love” and I feel everything that you said in that article like when you said “I believed that the relationship was holding me back. It had become hollow, empty of the intensity I longed for.” I have felt this way for about 2 months but I don’t want to break up with my girlfriend. I just don’t know how to get out of it. I still love her.
It takes me about 5 seconds to be aware of how I feel and to realize thawt
I need to respond to the messenger. Mothers who experience postpartum depression, frequently do ss in shame
and silence. ” Then just move on and enjoy our day, moment by moment:).
In my experience, some therapists do this also — look for a quick diagnosis they can target, and then zero in for the kill. I have had both cognitive behavioral therapists and others try to label me, sometimes within the initial evaluation session, before they’ve even listened to any real personal information. It always takes me by surprise because I expect them to listen first and treat after. They often jump to a totally wrong conclusion from quick observation or a few questions. To me, that should not be the nature of therapy. It should be a slow process involving a deft assessment of background info and involved attention to the story of the client, not checking off a list from the DSM. And more often than not, at least in my case, they tend to look for the proverbial zebra instead of the horse when they hear hooves approaching.
Hi, Donna –
There must be a lot of cognitive therapists around who have learned the technique in a rote way and don’t know much else. The worst experience I had was not with type but with someone who had a lot of sensitivity but also a lot of dogmatism. He seemed to think that having depression mean being immobilized in a psych ward and on suicide watch. Everyone else, he implied, was a victim of advertizing and didn’t really have a disorder. I didn’t stay with him very long.
Love the image of looking for the zebra instead of the horse. Gets it perfectly.
John
Just so happens I have had a recent “update” on this topic. For the first time in almost 20 yrs I went to a psychiatric hospital hoping for help in the form of an SSRI antidepressant. The one I had taken for years was suddenly making me dizzy. And the last thing I needed was a fall and a broken hip. My psychiatrist was not seeing patients in person due to the pandemic and I refused to do the online-video-appt. Seemed undignified for some reason. I wanted a face-to-face. My primary doc was hesitant to prescribe anything but gabapentin, which she seemed to think was some cure-all miracle drug, even for depression. No go. I turned up at a major university hospital where I used to work because treatment there is free for employees who worked there at least 10 yrs. After 100 yrs (uh, excuse me, that was 11 hours) in the ER after all personal items including purse and cell phone were stripped from me and a babysitter nurse sat with me till a psyche room was open, I asked to leave. Was told that if I tried to leave, the police would be called and it would become an INvoluntary admission instead of voluntary. I was not even allowed my phone back long enough to call a family member to let them know where I was. (Excuse me, but where is the logic in that?)
Once on the ward I knew I could ask for an AMA (leave Against Medical Advice). A young psychiatrist and intern interviewed me for maybe 20 minutes asking general questions. Their diagnosis was Borderline Personality Disorder. Talk about surprised — I still don’t know how they got that, but it is now on my permanent record as a diagnosis.
All of this to get a simple antidepressant, which supposedly 1 woman in 5 is now taking across the US. And get this: since depression was not their diagnosis and they agreed I could leave against medical advice since I was not suicidal, they would not prescribe an antidepressant. And I was charged $10,000 for this lovely hospital experience that lasted less than 24 hrs total. They actually told me I was lucky because one man was recently kept in the ER for 40 hrs before getting a bed in the psych ward.
I won’t go into it but there were even further serious indignities (besides just having my person searched when I was admitted.) I asked if they would do this if I was there for cancer or to give birth. I said anyone else wanting to leave the ER, even if they were having a heart attack or had a punctured lung, they would have to let that person go. Free will. But for someone asking for an antidepressant who is admittedly NOT suicidal? I think the Borderline Personality Disorder was a kind of punishment for my asking to leave. Not really, maybe…but it seemed pretty off the wall.
Anything can happen when you see a psychiatrist or if you volunteer to be admitted to a psychiatric hospital in order to get help for depression. Like you, John, some time ago another psychiatrist said he only did medication management, that if I wanted someone to listen to my problems I should see a therapist. I asked how he could make a diagnosis and prescribe medication without first listening to how I described my symptoms. He was the doctor, I was the patient, and had no right to question his superior diagnostic techniques…apparently. I moved on. Another told me I had narcissist personality disorder on the second visit. His reasoning was that everyone has some “symptoms” of NPD. Including himself, I couldn’t help but think. I would have been happy to have been evaluated for depression using the DSM criteria you mention. Even that doesn’t always happen.
And after this most recent fiasco at the university hospital, I went home and decided I was quite happy and blessed to be back in my own home, sleeping in my own bed. And people can’t understand why some people with depression turn to alcohol and street drugs. It is no mystery to me.
Fortunately, for me, when I was first diagnosed, my psychiatrist conducted a 90-minute evaluation. I don’t think those exist any more. My follow-up appointments are all 30 minutes, so I have no complaints with even my present doctor. He is also one of the few who actually do therapy, although I don’t see him for that.
In contrast, my younger son – who has been on Medicare and Medical Assistance for years and now also has private insurance from his employer – goes to a clinic where turnover is very frequent and I think the doctors there are frustrated because they are never allowed enough time to spend with patients, probably because it’s a non-profit and they are always short-handed. While his current doctor seems good, he can usually only get 15 minutes once every four months unless some crisis comes up, which it did recently while he was switching medications. I think it was not wise to put off seeing him for 4 months when he was still in the trial stages of the new drug. Also, because my son is developmentally disabled and autistic (although able to communicate), some of his doctors have seemed like they didn’t quite know what to do with him, while others went out of their way to figure him out. I have to go with him to his appointments to make sure they know everything that’s going on.
I agree with the idea of not identifying the person as the illness. In my experience, doctors have not relied solely on the DSM but I think you’re right about the insurance companies dictating how care is administered. My own doctor has his own private practice, in addition to working for a clinic, so that he can take the time he believes is needed with each patient, even though I know he doesn’t get reimbursed adequately from the insurance companies. And relying on primary care physicians to screen for things like depression doesn’t seem to cut it. Even when I’m actually depressed and fill out one of those screening tools, nothing is ever said about it. Plus, I don’t think they should be the ones overseeing a person’s medication but a lot of times, people just keep going back to the primary for their meds because it’s easier, when they really should be referred to a psychiatrist.
I think I love James Philips.
The big problem I think is that the money is allocated within a management/ command and control model.
Hi, Evan –
In the states healthcare money is managed through a huge variety of private and public insurance and reimbursement plans. But the changeover to the for-profit model in health care of the last few decades has forced most doctors into networks linked to major insurers and pension plans. And the pressure on all the health care providers is to push patients through in the most efficient way possible to keep expenses for routine care down. Efficient, of course, means 5-15 minute consults. The system is a mess and not a direct command and control one. In the end, though, patients have no control except through a broader requirement to give them adequate information. You have to be an activist in this system to be treated as an individual, especially when it comes to mental health.
John