The Conflation of Chronic Sadness With Major Depression

When I bring up with many other professionals the idea that major depression is now over-diagnosed by relabeling what used to be called dysthymia as "mild' major depression, a lot of them seem to disagree. Or they just tune out. “That’s just your opinion,” I might hear. Well, luckily the DSM-V now provides evidence that I am on the right track. In the DSM-V, the term “dysthymia” has been replaced! It is now called Persistent Depressive Disorder. 

As I have discussed in many previous posts, my opinion about major depressive disorder is that it is more of a brain disorder than mere unhappiness. The word depression itself is a symptom, not a disorder. It is in the interest of drug companies to conflate chronic psychological unhappiness with major depression so they can sell more antidepressant drugs to people who will not actually benefit from them.  Now,  it is also possible to have both, which is called double depression.

While many of the criteria are the same for the new diagnosis as the previous criteria for dysthymia, there are subtle differences that obscure the difference between that disorder and major depressive disorder. In a percentage of people with the latter disorder, it may become chronic. This is seen in the new definition of the disorder, which reads “This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. These disorders should not be consolidated.

There is one additional change which is telling. The only specific criteria for the disorder that has been changed has gone from “The disturbance is not better accounted for by MDD or MDD in partial remission” to “Criteria for Major Depressive Disorder (MDD) may be continuously present for 2 years, in which case patients should be given comorbid diagnoses of persistent depressive disorder and MDD."  Double depression has nothing to do with the length of the major depressive episode.

Drug companies have enlisted academic psychiatrists to become “key opinion leaders” in order to push this idea, and have even advocated the use self report surveys designed to screen for major depression (therefore having a lot of people test positive who don’t really have the disorder  – false positives) as diagnostic instruments.

This has led to a host of articles in the popular press that seem to indicate that antidepressants are nothing more than placebos. Nothing could be further from the truth, but a lot of psychiatry critics like Robert Whitaker have seized on “research” articles (which do a crappy job of making the correct diagnosis) that seem to show this to be the case.  After all, since most anti-depressants are generic,  it's better for drug companies' bottom line if instead of those drugs, expensive new anti-psychotic drugs can be recommended instead.

The critics also use the fact that we don’t know exactly what causes major depression to dismiss the whole diagnosis. The incorrect hypothesis that the condition is due to a “chemical imbalance,” which is sometimes advanced by clinicians, must mean that it is not a real disease. Dumb. Clinicians have often used this oversimplified idea to convince resistant patients to take the medications. Researchers rarely if ever actually said that a chemical imbalance was the cause of the disorder.

Of course, it’s not always easy for clinicians to tell the difference between dysthymia and major depression in a given patient, but in most cases it’s fairly straightforward.  There is nothing that stops anyone from being chronically unhappy when they are not having an episode(the euthymic state) of major depression. And major depression is episodic with normal-for-them baseline mood periods in between episodes.

A good clinician will define a response to antidepressants as good if the patient returns to their baseline. They don’t have to be in a good mood to have had a good response, but may just need psychotherapy like any other dysthymic patient. Nonetheless, many of these patients who have double depression are mislabeled in the literature as “treatment resistant,” which means that docs are encouraged to add still more drugs to antidepressants to “augment” them. There are of course patients who actually are treatment resistant and need this augmentation, but in my 45 years of practice this was a relatively small contingent.

Briefly and in an oversimplified manner, distinguishing the two disorders has to do with the “three P’s” – persistence, pervasiveness, and pathological. (You can tell if a study employs the correct definitions by seeing how the diagnosis was made with their subjects. The P’s are emphasized in an excellent diagnostic interview called the SCID). Persistent: this is the duration criteria. An episode has to last at least two weeks. Admittedly, the two-week criteria is arbitrary, but is put in so clinicians don’t make the diagnosis after too short a period.  The “everything is bipolar” crowd routinely poo poo's the duration criteria.

Pervasive: the symptoms have to be present nearly all day every day no matter what goes on in a patient’s life. This means that if a patient were to win the lottery, it wouldn’t cheer him up all that much.  Pathological: this means that the ways that the patient reacts to any stress is different from the way they might react if they were not in an episode. See the lottery statement. Also, if a lover were to, say, break their heart, this would not always make a whole lot of difference in how bad they feel.

These issues are not seen with good doctors, who not only know how to take a complete bio-psycho-social history but actually still do them.

Depression is a Symptom, Not a Psychiatric Disorder

Lately there have been a slew of articles about "depression" that seem to go out of their way to avoid discussing any specific psychiatric diagnosis listed in the DSM - instead strongly implying that "depression" is itself a disorder. These articles appear in the popular press, but, frighteningly, also in newsletters and newspapers for psychiatrists and psychologists. They explore such questions as "Do antidepressants work?" and "What is better for depression, drugs or cognitive behavioral therapy?"

These types of questions are completely meaningless. Depression is discussed as if it were a single phenomenon that, at best, exists on a continuum from "mild" to "moderate" to "severe." This type of wording is in fact completely ignorant, but does not necessarily reflect real ignorance. In many cases, different entities such as big Pharma have a vested interest in conflating several different psychiatric conditions.

In truth, "depression" is just a mood state, and as a symptom, it can be part of many different psychiatric disorders that are, despite some overlap in symptomatology, as different as night and day when it comes to their clinical presentations as well as their response to various treatments.

To name but a few actual diagnoses, there is major depression (both as part of unipolar and bipolar disorder), dysthymia, adjustment disorder with depression, depression due to a medical condition, and depression due to a substance. Medical conditions that can lead to depressive symptoms include hypothyroidism and some strokes. Substances that can do that include some steroids like prednisone and the "crash" that results when an acute cocaine high wears off.

Furthermore, "depression" as discussed in every day conversation can be a normal mood that is part of chronic unhappiness, or that occurs in response to grief at someone's death or due to any other loss or misfortune.

The most important diagnostic distinction for this discussion is between major or clinical depression and dysthymia. Although we don't know enough about the brain to know the exact causes of either one, and there is some overlap in symptomatology, they appear for the most part with very distinct clinical presentations, especially in their classic forms.

Dysthymia appears to be more of a psychological reaction, while major depression probably involves the more primitive part of the brain called the limbic system. The latter, unlike the former, is accompanied by a whole array of chronic, persistent (lasting all day every day for at least two weeks), and pervasive (coloring all aspects of the patient's mental life) physical symptoms - all at the same time - involving sleep, appetite, ability to experience pleasure, energy level and motivation, and concentration. Sufferers may have an unrelenting and constant sense of foreboding accompanied by inexplicable hopelessness and helplessness. We used to refer to these types of symptoms as vegetative symptoms.

Furthermore, someone in a major depressive disorder episode reacts completely differently to life's every day ups and downs than they do when they are not in the middle of such an episode. It's almost Jeckyl and Hyde territory.

These people stay depressed no matter what life events occur around them. They could literally win the lottery and would not really feel a whole lot better for more than a few minutes.

The most severe form of major depression is called melancholic depression. Most people who have never worked in a mental hospital have never seen a case, but the anti-psychiatry types who have not seen it blather on about depression incessantly as if they knew what they were talking about.

People with melancholic depression exhibit something called psychomotor retardation. People with this symptom move and think at a snail's pace.  It takes them longer to respond to any verbal interactions. They can even appear to have significantly impaired memory, although it is actually a more severe form of concentration impairment. That clinical picture is sometimes referred to as pseudodementia. 

You cannot spend more than an hour with such people without realizing that this condition has next to nothing in common with the type of "depression" people see in their everyday interactions with others, and that there is something seriously wrong with their brain functioning.

In severe major depression, doing any kind of psychotherapy (short of telling them, "take these pills") is a complete and utter waste of time. Sufferers literally do not have the mental wherewithal to deal with any kind of problem solving or other interactions with a therapist. And I say that as a major advocate of psychotherapy.

The symptom of depression in dysthymic disorder, on the other hand, rarely responds to antidepressant medication at all (although the drugs can be useful for other symptoms seen in patients with dysthymia such as panic attacks, obsessive ruminations, and the affective instability characteristic of borderline personality disorder). For these folks, psychotherapy is essential.

In my experience a very high percentage of the people who do drug and psychotherapy outcome studies, at least in adults, make almost no meaningful effort to differentiate dysthymia from major depression by: 1) Not spending any time making certain that patients understand the pervasiveness and persistence criteria that differentiate the symptoms of the two disorders; and by 2) Not taking a complete biopsychosocial history to distinguish psychological from limbic system factors.

All of the fancy biological research is not being complemented by good old fashioned clinical typing.

Furthermore, with the private Contract Research Organizations that do a lot of the studies, experimenters get paid only if they recruit a subject, and subjects get paid only if they get recruited - giving a financial incentive for everyone to exaggerate symptoms in order to qualify.

And people with suicidal ideation, comorbid (other, co-occurring) conditions, and significant personality pathology are excluded from studies. Those "exclusions" eliminate the vast major of subjects that have any of the psychiatric disorders in which depression is a symptom.

Garbage in, garbage out.

By the way, you can also have something called double depression. Such people are generally dysthymic but every so often can have a superimposed episode of major depression. So they have both conditions.

Once a major depressive episode starts to occur, it takes on a life of its own. However, being chronically unhappy, anxious, or stressed out may be risk factors for triggering a major depressive episode to begin with.  If you are genetically vulnerable to an episode of major depression, being chronically unhappy might make an episode more likely.

This is another reason why the question, "Should you treat these people with medications or therapy" is a really stupid question. It's a bit like asking, "Which treatment should people who have extensive, severe, cardiovascular disease get, bypass surgery or high blood pressure medication?" 

These treatments address completely different aspects of the disorder. In major depressive disorder, drugs should be used during the acute disorder, but psychotherapy should be given later to address personality  and relationship risk factors - in order to reduce the likelihood of subsequent episodes.