What is depression?
Depression, known clinically as major depressive disorder, is an illness characterized by low mood and loss of interest and pleasure in activities that were once enjoyed. It is one of the most frequent diseases in humans, and can appear chronically, with recurrent episodes. In Spain alone, it is estimated that around 4 million people suffer from depression, approximately 8.4% of the population.
It is a much more frequent affliction in women, something further accentuated by severe depression (for every man with severe depression there are 3.5 women). Although it has somewhat improved in recent years, there is still a lot of stigma around depression, which leads many to hide their suffering and causes difficulties in their treatment. Additionally, mental health places an immense burden on our public health system, which is far from being sufficiently prepared for its detection and treatment. In Spain there are waiting lists of at least 3 or 4 months, and achieving adequate follow-up (rather than purely pharmacological) is extremely difficult.
Diagnosis and symptoms of depression
Today, the most widely used criteria for the diagnosis of major depression and other mental disorders is the DSM-V (Diagnostic and Statistical Manual of Mental Disorders), written by the APA (American Psychiatric Association). Diagnostic criteria began to be standardized after the Second World War, to treat returning soldiers with different disorders and difficulties. It has been edited and revised by the APA over the years, with the latest edition, the DSM-V, published in 2013. Another manual employed frequently is the ICD-10 (International Classification of Diseases) written by the WHO (World Health Organization).
To make a formal diagnosis with a psychiatrist, the symptoms have to cause significant impairment in some area of functional life, such as social or work life. Symptoms must be present for at least 2 weeks, but usually last longer. One of the first two symptoms described below, and four additional ones, must be present for a DSM-V diagnosis of major depression:
1. Depressed mood for much of the day and for almost every day.
2. Decreased interest or pleasure in activities, hobbies, the environment, etc.
3. Decreased concentration.
4. Changes in weight or appetite.
5. Insomnia or sleepiness almost every day.
6. Feelings of guilt, usually inappropriate or excessive, or worthlessness.
7. Lack of energy, fatigue almost every day.
8. Psychomotor changes – can appear in many ways, such as agitation, or slowing down of the gait.
9. Recurring thoughts of death and ideas of suicide.
Leaving the framework of the DSM-V aside, it is important to note that there are other symptoms of depression not indicated in the manual. It is a disease that can present itself in extremely varied ways between individuals. This can make its diagnosis difficult, since the indicated criteria are not met, but even so, there is true suffering on the part of the person.
Although a sad and discouraged mood is most commonly associated with depression, it can also express itself through high irritability, anxiety, lack of illusion and even anger. Anhedonia or apathy is also very common, and this can lead to emotional flattening – a state of indifference rather than sadness or irritability. The tendency to procrastinate increases, since there is usually a greater lack of initiative or less motivation.
Some cognitive symptoms may also be present. Concentration and attention problems are the most frequent, but memory problems can also arise, generally linked to attention failures. Lastly, the physical symptoms, such as changes in sleep, appetite, and energy, are very common and extremely difficult to treat. These symptoms cause a direct impact on mood and physical health, thus worsening depression, which in turn makes it difficult to change bad habits associated with these physical symptoms. It is a very difficult pattern to break for someone with depression.
The most important thing to emphasize here is that depression can express itself in many different ways. Where someone can isolate themselves and stop communicating with others, another person can do the opposite, socializing in search of constant distractions. Pain doesn’t always live in plain sight. It is vital, both for the professional and for friends and family, to listen to the person who is suffering, to not minimize their pain, and to offer support through a respectful and patient stance.
Problems with the categorization and classification of mental disorders and the DSM-V
There is much criticism from mental health professionals (and from patients as well) about the rigidity of the diagnostic criteria found in the DSM-V and other diagnostic manuals. It should be noted that 69% of those in charge of drafting the DSM-V have direct ties to pharmaceutical companies, calling into question the integrity and influence exerted on this manual.
On the one hand, the DSM-V is useful for establishing standardized guidelines and criteria for the diagnosis of mental disorders. It provides a regulatory framework that healthcare professionals can use, and offers a standard for conducting research. On the other hand, the DSM simplifies mental health to a series of criteria and numbers, which does not encompass the complexity of human behavior. Those who do not meet these criteria, despite their suffering, usually do not receive adequate help. Setting such rigid criteria can also lead to misdiagnosis or overdiagnosis. Finally, as we have already mentioned, the stigma around mental health still exists, and the use of labels and categories to define people can be harmful on a personal, social and work level.
There are currently several alternatives to DSM-V and ICD-10. The PDM (Psychodynamic Diagnostic Manual) attempts to integrate a personality assessment into diagnosis, based on psychodynamic theory. The PTMF (Power Threat Meaning Framework), the most radical proposal, completely rejects psychiatric diagnosis, and instead analyzes how oppressive power structures create harmful methods and behavior to deal with these structures. However, none of these alternatives are well known in the world of mental health, and therefore they are rarely used and their research development is almost non-existent.
Many professionals believe that although diagnosis can offer practicalities in research and other more bureaucratic issues (such as health insurance and hospital care), it can also be detrimental during therapeutic treatment. The DSM reduces human suffering to a ‘broken’ brain, which treats psychosocial factors as external to grief. The main problem boils down to internal dysfunction, ignoring the complex interplay of psychological, social, contextual, and biological factors. In order to offer a more humane and empathetic accompaniment, we must move towards a more holistic perspective of mental health, in which the multiplicity and complexity of the person and the world around them are taken into account.
