The problem with depression is that EVERYBODY is an expert–which is, of course irritating to those of us who ARE experts–but I digress. That is, everyone has experienced the feeling of depression. I like to describe it as hopeless, helpless, and worthless. Just think of the first time your boyfriend or girlfriend dumped you for your best friend, that’s depression.
Problem is, the feeling of depression is not the same as the disease of depression. Bob Golden, one of my teachers during residency, used to say, “Not everyone who is depressed has depression and not everyone who has depression is depressed.” Confused?!? The important thing is to distinguish the feeling of depression from the disease of depression.
The disease of depression is an abnormal mood state that lasts most of the day for weeks on end. The official diagnosis requires two weeks, but, untreated, the disease of depression often lasts 9 months or more. Now, to complicate matters, there’s another form of depression called dysthymic disorder which is a low level of depression that lasts for years–but more on that topic later.
Now, the abnormal mood state might consist of sadness, hopeless, helplessness, or worthlessness. It might be characterized by inactivity or crying spells. But I’ve had plenty of patients who complain of numbness, a feeling of ‘I don’t care’ or, especially in men, irritability. Some patients feel anxious and agitated. The key description of an abnormal mood state is that you just don’t feel like yourself.
The more I treat depression, the more I realize that it’s not just a mood disorder, it’s also a thought disorder. The official diagnosis has criteria of poor concentration, indecisiveness, and psychomotor retardation (what the heck is that?!?) People with depression complain of distractibility, confusion, and feeling overwhelmed, muddled and disorganized. I notice that when their depression is treated, they solve problems that seemed impossible when they were depressed. These thinking problems occur because perceptions are colored by the negative mood but also because thinking itself is slowed and confused.
OK, OK, OK, so what is psychomotor retardation? When I look at a patient, I have some idea of a ‘normal’ rate of speech, a ‘normal’ reaction time, a ‘normal’ speed of movement. If the patient is slowed from my perception of ‘normal,’ I say that person has psychomotor retardation. Have I ever mentioned to you how much I hate the word ‘normal?’ Implicit in the term is the idea that abnormal is bad. Have you watched any reality shows lately? Do you REALLY want to be ‘normal?’ But I digress…. Here’s the problem with the whole ‘psychomotor retardation’ concept though. I often see patients who don’t look abnormal in the speed of their movements or speech, but when I see them well, I realize they were actually quite slowed down–for them. Bottom line, as a criterion, this one has limited utility.
People with depression have disturbances of sleep. OK, prepare for more confusion. They might complain of insomnia or they might sleep excessively (hypersomnia, if you want to get fancy). The classic sleep problem for depression is early morning awakening, but I hear all kinds of sleep complaints. The complaint of fatigue goes along with the sleep disturbance. The fatigue of depression can be quite dramatic. I get many patients sent over from their family doctors whom they consulted because they were sure they had cancer or some other dread disease because they were so fatigued.
I did my undergraduate studies at the University of Pittsburgh in the dark ages. We walked to school barefoot in the snow uphill both ways AND we didn’t even have Prozac, but I digress…. I had a professor who suffered from a severe depression and was participating in some early clinical trials at the Western Psychiatric Institute, a pretty snazzy place associated with the medical school there. He wore this box that measured movement on his wrist. His treatments were considered successful if activity increased during the day (increased energy) and decreased at night (improved sleep). I thought that was pretty nifty. OK, OK, OK, so I’m a science nerd, I can’t help it…
People with depression have disturbances of appetite. In our usual psychiatric muddle, food intake and weight can go up or down. Almost always, though people with depression are not enjoying their food like they usually do. People with depression don’t enjoy most things like they usually do. One of my favorite patients measures her degree of depression by how much she is shopping–a woman after my own heart. Other patients talk about not wanting to socialize as much.
The old analysts used to describe depression as anger turned inward. Certainly, people with the disease of depression don’t like themselves very much. They feel excessive guilt. (I once asked a woman if she were experiencing excessive guilt, and she replied, “You don’t have children, do you, Dr. Ney?” And she wasn’t very nice about it either. So I don’t ask that question anymore.)
The suffering of depression can be severe. I’ve had patients who recovered from severe depressions and later got cancer and had chemotherapy with all the nausea, vomiting, hair loss, and misery of that. They’ve actually told me that the depression was worse than the cancer. The disease of depression is obviously not the same as getting dumped by your high school sweetheart.
The severity of the suffering, combined with the inability to see solutions to problems, combined with a sense of worthlessness and guilt can be severe enough to cause suicidal thoughts and feelings. Suicidal ideation is a whole topic to itself–more on that later.
So, there are nine criteria to diagnose depression: abnormal mood, decreased pleasure, appetite disturbance, sleep disturbance, fatigue, poor concentration, guilt or low self-esteem, psychomotor retardation, suicidal ideation. If you have 5 or more of these (one of the 5 must be abnormal mood or decreased pleasure) for 2 or more weeks, bingo! you get a diagnosis of Major Depression. Other labels you may have heard for this condition include clinical depression, endogenous depression, or chemical imbalance. Notice this well! There is no blood test, scan, written test or other objective measure that tells us if you have the illness of depression. This lack of objective measures is hugely important when we start talking about treatment–which we will and soon.