Diagnosis of Clinical Depression
Mental health professionals and physicians are careful and deliberate when evaluating their clients for clinical depression. It takes more than just tearfulness or a feeling of sadness on the part of the client to indicate the presence of depression. A professional should take the time to gather a good deal of information about a person before determining that he or she is clinically depressed. In addition to a medical evaluation, a clinical interview, and possibly additional assessments, a professional will evaluate whether a person has specific symptoms of a mood disorder such as major depression, dysthymia or bipolar disorder. Each mood disorder is characterized by a unique set of symptoms, or diagnostic criteria, which are listed in a publication called the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition, Text Revision.
Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Text Revision (DSM-IV-TR)
The Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition, Text Revision (American Psychiatric Association, 2000) is the current reference used by mental health professionals and physicians to diagnose mental disorders. This publication is often referred to as the DSM or DSM-IV, and we use such abbreviations here for convenience. The American Psychiatric Association began publishing the DSM in 1952, and it has since gone through several revisions before the most recent version, the latest edition was published in 2000. An updated edition is expected in 2012. The current DSM-IV-TR lists over 200 mental health conditions and the criteria required for each one in making an appropriate diagnosis.
Diagnostic criteria for mental disorders are essentially descriptions of symptoms that fall into one of four categories. In major depressive disorder for example, affective or mood symptoms include depressed mood and feelings of worthlessness or guilt. Behavioral symptoms include social withdrawal and agitation. Cognitive symptoms, or problems in thinking include difficulty with concentration or making decisions. Finally, somatic or physical symptoms include insomnia or hypersomnia (sleeping too much).
The clinical usefulness of the DSM-IV-TR is much more than a tool for making diagnoses. It is used by mental health professionals and physicians as a guide for communicating about mental health conditions. When two clinicians discuss a diagnosis such as “major depressive disorder, single episode, severe with psychotic features,” they both have the same conceptualization of various aspects of the illness. Without the DSM-IV-TR, the two clinicians might have very different perceptions of the condition. The DSM-IV-TR also allows mental health professionals to reach consensus on which symptoms or groups of symptoms should define which disorders. Such decisions are based on empirical evidence (research results), usually by a multidisciplinary staff of professionals. Further, the DSM-IV-TR is used as an educational tool and a reference for conducting all types of research (e.g., clinical trials, prevalence studies, outcome research).
The DSM-IV-TR is not used to categorize people, but to categorize conditions or disorders that people have. This may be a subtle distinction, but it is a very important one. We do not say that a person is cancer, or is heart disease, or is an illness. A person has an illness. Likewise, we should not say that a person is a depressive, but that a person has clinical depression. Along the same lines, the value of diagnostic labels is often debated among mental health professionals and the general public. On the negative side, some people believe that making a diagnosis is simply the act of labeling a person. Once a person is labeled he or she may have difficulty overcoming the label, may lose hope of recovery, or may come to believe that he or she is the label. On the positive side, some people are relieved when they finally learn that the symptoms they are experiencing have a name. This often offers a sense of hope and personal control over the illness as more can be learned about its treatment, causes, and outcome.
The depressive disorders that are described on this web site are grouped under a category in the DSM-IV-TR called Mood Disorders. Included in this category are major depressive disorder, dysthymic disorder, bipolar disorder, cyclothymic disorder, mood disorder due to a general medical condition, and substance-induced mood disorder. Two subtypes of mood disorders include seasonal affective disorder and postpartum depression, while premenstrual dysphoric disorder has been proposed as a diagnosis for further study. For each of these mood disorders there are specific criteria that a person’s symptoms must meet in order to receive a diagnosis.
Once a diagnosis of a particular mood disorder is made, more detailed information about the diagnosis can be provided in the form of “specifiers.” The use of specifiers gives mental health professionals and physicians more information about a person’s condition, helps with choosing which treatment may be most effective, and aids the prediction of the course and prognosis of the illness. You might think of specifiers as being sub-categories of the larger categories of major depressive disorder, bipolar disorder, and so on.
For instance, take a look at the following two diagnoses:
* Major Depressive Disorder, Single Episode, Moderate, With Atypical Features
* Major Depressive Disorder, Single Episode, Moderate, With Melancholic Features
Both diagnoses indicate the presence of the mood disorder- major depressive disorder. Specifiers that follow show the presence of a first or single episode of depression that is moderate in severity. These diagnoses look very much alike. You might think that two people, each given one of these diagnoses, may seem to be experiencing similar depressive symptoms. For the most part they may be, but ultimately there are some subtle yet very important differences. If you take a look at the specifiers that are described below, you will see that “atypical features” of depression are slightly different than “melancholic features.”
Specifiers associated with the mood disorders are listed below:
* Mild: A few symptoms, if any, are present beyond what is needed to make a diagnosis, and a person can function normally although with extra effort.
* Moderate: The severity of symptoms is between mild and severe. For a manic episode, a person’s activity is increased or judgment is impaired.
* Severe Without Psychotic Features: Most symptoms are present and a person clearly has little or no ability to function. For a manic or mixed episode, a person needs to be supervised to protect him/her from harm to self or others.
* Severe With Psychotic Features: A person experiences hallucinations or delusions. Psychoses may develop in about 15% of those with major depressive disorder. The presence of delusions and hallucinations often interfere with a person’s ability to make sound judgments about consequences of their actions and this may put them at risk for harming themselves. Psychotic symptoms are serious and a person in this condition needs immediate medical attention and possibly hospitalization.
* Single Episode/Recurrent: A first episode is considered “single,” subsequent episodes are “recurrent.”
* In Partial/Full Remission: There is full remission when there is an absence of symptoms for at least two months. For partial remission, full criteria for a major depressive episode are no longer met, or there are no substantial symptoms but two months have not yet passed.
* Chronic: For at least two years a person’s symptoms have met criteria for a major depressive episode.
* Catatonic Features: Unusual behaviors or movements such as immobility, excessive activity that is purposeless, rigid or peculiar posturing, mimicking others’ words or behaviors.
* Melancholic Features: A loss of pleasure in most activities or an inability to feel better, even for a short time when something pleasurable happens. Also, at least three of following is present: the depressed mood is distinct (i.e., unlike feelings of bereavement), it is worse in the morning, a person wakes too early in the morning, there is distinct agitation or movements are slowed down, substantial weight loss, or extreme feelings of guilt. Melancholic features are associated with a person experiencing a specific precursor to the illness and having a better response to antidepressants. Men and women may equally have these features, although they are more common in older people. They may also be more likely to occur in more severe depressive episodes, particularly ones with psychotic features.
* Atypical Features: During the last two weeks of major depression or bipolar disorder (depressive episode) or the last two years of dysthymia, a person is able to experience brightened mood when good things happen. Also, at least two of the following must be present: substantial gain in weight or appetite, sleeping too much (at nighttime or daytime napping that is at least 10 hours total or two hours beyond normal), body feels heavy or weighted down, or persistent sensitivity to rejection by others that is related to personal or social difficulties. The sensitivity to rejection tends to be a more long-standing problem. The presence of depression may increase the sensitivity, although it is often still present when the person is not depressed. Atypical features occur two to three times more often in women. They are also associated with depression beginning at an earlier age (e.g., teens) and possibly more chronic depressive episodes. Personality and anxiety disorders may also be more common.
* Postpartum Onset: The depressive episode begins within four weeks of giving birth.
* With/Without Full Interepisode Recovery: Describes a long-term course of recurrent major depression or bipolar disorder. The specifiers indicate whether a person recovered from his/her symptoms between the two latest episodes.
* Seasonal Pattern: Describes a pattern of depressive episodes in recurrent major depression or bipolar disorder. The symptoms tend to begin (usually fall or winter) and end (usually spring) at particular times of the year.
* Rapid-Cycling: Describes a recurrent pattern of depressive and manic episodes in bipolar disorder. A person has had at least four mood episodes during the last 12 months. There is either a general absence of symptoms between episodes or a clear switch from one to its opposite, such as from depression to mania. Rapid-cycling may affect5% to 15% of those with bipolar disorder, and women account for 70%-90% of those with this pattern. Certain medical conditions may be related to rapid-cycling such as neurological problems, hypothyroidism, head injury, and mental retardation, as well as treatment with antidepressants. Those who develop a pattern of rapid-cycling may have a less favorable prognosis.