One in five of our population has a depressive illness at some stage in their lifetime and the rising tide of suicide is largely attributed to depressive disorders.
Despite the scale of the problem, there are some who question the existence of depression. Some have even have gone so far as to describe all mental illness as a “myth”.
Psychiatrists are medical doctors who diagnose and treat depression. In a climate of scepticism, fear and denial, mental health professionals, ideally working in a multidisciplinary team, are tasked with explaining and supporting a decision to treat mental ill-health.
This decision should be based on a diagnosis, arising from a detailed assessment interview or series of interviews. This assessment follows structured guidelines, but, unlike other areas of medicine, is still dependent on clinical skills without investigations, tests or biopsies. There are no diagnostic X-rays or definitive measures. The diagnosis depends entirely on the quality of the communication and the observations of the doctor.
It was often said that “doctors differ and patients suffer”. To limit this problem, the diagnosis of depression is made consistently and reliably by ensuring that clear guidelines are followed. These reliable diagnostic systems (known as ICD or DSM) have themselves come under fierce criticism. The criticism of DSM or ICD is that, even though they may make diagnosis more reliable, they may also facilitate making diagnoses which are not real.
Depression is a real diagnosis which can now be reliably made and which is valid.
Making a diagnosis of depression using ICD requires the presence of substantial numbers of symptoms which are present in a persistent, pervasive and profound fashion. Crucially, the symptoms must be a substantial impediment to daily living and independence, at work or at home.
Although some people feel frightened by any diagnosis, many more are hugely relieved that their suffering has been heard and understood, and that a plan for their care can be started. The sense of being understood is associated with relief; the affirmation of suffering is associated with the opportunity for hope rather than despair.
This hope is also valid since depression is a very treatable condition. The evidence suggests that less than 40% of people with depression get any professional help. Those who do seek help have often have symptoms unaddressed for many months or even years. With proper assessment and diagnosis, recovery can begin within weeks of commencement of a treatment plan.
One group of objective symptoms and signs in depression is without question valid and indicative. These are called "melancholic features" and they indicate a chemical basis for depressive illness. Melancholic features appear in addition to the core of low mood, loss of pleasure, guilt, despair and suicidality. They manifest as:
- early morning wakening
- morning dread with lifting of mood in the evenings
- loss of appetite with significant weight loss
- slowing of subtle cognitive and motor functions and/or psychosis (loss of reasoning).
When these features are present, not only should a clinical depression be diagnosed, but appropriate treatment (including medication) should be introduced.
There are many who question whether the mental health disorders described in ICD or DSM are genuine or justifiable. However, objective mental health disorder does exist and it is valid, just and necessary to acknowledge this.
Diagnostics, it is argued, increase stigma though labelling. However, the stigma of mental illness is inevitably increased by doubts surrounding the legitimacy of making a clinical decision on a syndromal basis. Understandably, some people feel stigmatised by having a diagnostic label attached to their problems, but others feel enormous relief. This diagnostic relief comes from the affirmation of personal suffering and the experience of being heard and understood. When this is followed up with a care plan and a roadmap to recovery, then the diagnosis is often welcomed, as a significant breakthrough which allows recovery to take place.
Mental health diagnoses probably tell us nothing about the causes of mental health disorder, but diagnosis does help with the acknowledgement of mental health needs and may be of critical importance when forming a care plan.
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