The World Health Organization (WHO) recently stated that depression is the biggest mental health threat to public health and is soon to become the second leading cause of disability worldwide behind heart disease, prompting some to declare that we have entered the Age of Depression! In 2009, in the USA, the Centers for Disease Control and Prevention reported that depression accounted for 21 million of the 51.7 million outpatient visits for mental health care in 2002.
Prior to the development of the Diagnostic and Statistical Manual (DSM-III) of the American Psychiatric Association in 1980, the diagnosis of depression (called Major Depressive Disorder in DSM-III) was restricted to those disabled enough to require hospitalization. When the diagnostic criteria were applied to untreated community samples, the diagnosis of depression increased dramatically. Early epidemiological studies reported rates of between 3-6%; later studies reported that 20% of the general population was depressed, while the most recent studies estimate that 40% of the community is depressed! How can this be?
The DSM-III established a set of “objective” symptom-based criteria by which depression could be identified. The problem is that these symptoms were very broad and encompassed feelings of worthlessness, emptiness and suicidality at one extreme to common symptoms such as insomnia, fatigue and change in sleep and appetite patterns at the other. The diagnosis could be given if the symptoms persisted for two weeks or more, so little distinction was made between the short-lived fluctuations in mood that we all experience to the more chronic, unrelieved and debilitating experiences of the seriously depressed person.
Further, although bereavement was excluded from the diagnosis, except when it was prolonged and unresolved, other frequent life experiences such as relationship breakdown, loss of a job, or failing an exam were not excluded from the DSM definition. Thus, brief, expectable and “normal” reactions to life stressors were now subsumed under the rubric of depression. When the diagnosis requires only a two-week duration of symptoms, many false positive diagnoses (i.e. identifying a condition when it does not exist) will be made if we apply the accepted diagnostic criteria.
For many people, severe depression has its origins in early life. Early trauma, loss or separation, economic hardship, chronic illness, social isolation or dislocation, bullying, domestic violence, having rejecting, indifferent, mentally ill or substance abusing parents are background factors that contribute to increased psychological vulnerability to subsequent stressors. Stressors experienced in adulthood such as working in dysfunctional workplaces, marriage dissolution, job loss, and significant bereavement inter alia are strongly associated with depression in most people, but people who had secure early life experiences will recover once the stressors have been removed, managed or worked through.
Mood disorder diagnoses nearly doubled over the ten year period from 1987 (20 percent of outpatients) to 1997 (39 percent of all outpatients) at a time when new antidepressants such as serotonin reuptake inhibitors (SSRIs) were becoming available. By 2000, antidepressant medications were the best selling drug class in the USA – 10% of the US population was using an antidepressant!
Depressed feelings are ubiquitous and it is important not to “over-medicalize” the human condition. David Malan, a British psychotherapist, observed that many people who present to health services are given a diagnosis of depression, for which they are prescribed antidepressants; or anxiety, for which they are prescribed anxiolytics, when the true diagnosis is “unexpressed painful feeling for which the treatment is to express it.”
Careful assessment is needed before proceeding to intervention. It is rarely a case of medication or therapy, and if therapy, cognitive behaviour therapy or psychotherapy. In the early stages of a severe depression, medication may be essential; for mild and moderate depression, cognitive-behavioral therapy, interpersonal psychotherapy, and psychodynamic therapy all show efficacy. The latest (2010) American Psychiatric Association practice guidelines for the treatment of depression emphasize the importance of establishing a therapeutic alliance with the patient, regardless of treatment modality. This includes awareness of transference (patient’s perception of doctor) and counter transference (doctor’s perception of patient), even if these are not directly addressed in treatment. The concepts ‘therapeutic alliance’, ‘transference’ and ‘counter transference’ were developed within psychoanalytic theory but are now widely applied because they affect treatment outcome - whether pharmacological or psychological. Patients want to feel cared for, heard and respected by their treating physicians and this aspect of the doctor-patient relationship may be as important as the intervention itself.
Choice of medication or therapy (and which therapy) will depend on the goals of treatment, psychosocial history, symptom severity, suicidality, comorbid conditions, treatment availability, and patient preference and suitability for particular treatments. While both medication and psychotherapy relieve symptoms, only psychotherapy addresses the chronic dysphoria of characterologically depressive people. Relationship, marital and family issues and current life stressors also need to be assessed and managed or treated, if necessary..