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Diagnosis
CBS CARES: How are the different types of depression diagnosed?
DR. KAHN: We don't have laboratory tests for depression, but rely on a cluster of symptoms that psychiatrists have agreed best describes the disorder. There are three categories of depressive illness: 1) Major depression, which is severe but usually episodic; 2) Dysthymic disorder, which is milder but chronic, lasting for at least two years; and 3) depression in bipolar disorder, or manic-depressive illness, in which periods of depression may alternate with periods of high energy or irritability, known as mania.
The standard definition of major depression comes from the American Psychiatric Association's (APA) Diagnostic and Statistical Manual, Fourth Edition (DSM IV). The APA provides this summary:
Major depression is diagnosed if a person experiences 1) persistent feelings of sadness or anxiety or 2) loss of interest or pleasure in usual activities in addition to five or more of the following symptoms for at least 2 consecutive weeks.
•Changes in appetite that result in weight losses or gains not related to dieting
•Insomnia or oversleeping
•Loss of energy or increased fatigue
•Restlessness or irritability
•Feelings of worthlessness or inappropriate guilt
•Difficulty thinking, concentrating, or making decisions
•Thoughts of death or suicide or attempts at suicide
Depression is diagnosed only if the above symptoms are not due to other conditions (e.g., neurological or hormonal problems) or illnesses (e.g., cancer, heart attack) and are not the unexpected side effects of medications or substance abuse.
CBS CARES: If depression causes chemical changes, why is there not a blood or tissue test to diagnose depression or risk of depression?
DR. GLASSMAN: There are chemical changes in depression, but they are not always the same in all individuals. On the average, many depressed patients have abnormalities in serotonin receptors, but not all patients show these abnormalities. In a similar way, many patients have increased plasma norepinephrine levels or cortisol levels, but again, these are not consistent, certainly not consistent enough to be used to establish the presence of depression. You can be severely depressed and not have any of these markers. For these reasons, there is no chemical test for depression.
CBS CARES: Can brain scans/imaging further understanding, diagnosis and treatment of depression?
DR. SILBERSWEIG: Absolutely. A revolution is currently taking place, as brain changes in depression, as in other disorders, are being mapped out. Combined with clinical, psychological, basic neuroscientific and molecular/genetic approaches, new methods of brain imaging are increasing our understanding of depression. This provides a foundation for the development of new, more targeted diagnostic and treatment strategies that hold promise for patients. In the future, biological tests and more specific treatments will most likely supplement the current approaches.
CBS CARES: Currently, isn't the diagnosis of depression ultimately subjective? How do misdiagnoses occur?
DR. KAHN: It's true that we depend on what the patient and family tell us to make the diagnosis. While we don't have blood tests or X-rays that will provide confirmation, well-trained mental health professionals can obtain accurate information, and a medical evaluation can rule out other causes. Research studies have shown that two psychiatrists evaluating the patient independently will almost always agree on this diagnosis. The most common misdiagnosis is failure to recognize bipolar disorder, in which patients have histories of both depression and episodes of elevated or irritable mood termed mania or hypomania. The treatment of bipolar disorder is quite different, and the key again is a well-trained, skillful and thorough interview. Other common misdiagnoses are failing to recognize physical illnesses that mimic depression, such as thyroid disease, or missing the role of substance abuse in triggering mood episodes.
CBS CARES: If a teen is angry, critical and uncooperative, how can parents know whether their child is suffering from major depression or is just having a hard adolescence?
DR. SHAFFER: Irritability, stubbornness, and hypercriticism of the family are often found in depressed teenagers, but they are not, in themselves, diagnostic criteria, unless they are shown to a broader group of people. Is the teenager's difficult behavior only present at home? Are they cheerful, cooperative, enthusiastic, friendly to others at school, and able to maintain a normal social life with people outside of the family? If so, it will often, but not always, indicate problems within the family, rather than a more general psychiatric illness. However, this is not always true, because many teens feel "safe" enough at home to show their true feelings and are on their best behavior in front of others. Are other symptoms of depression present? Is the difficult teen having a problem sleeping well or sleeping too much? Has their appetite changed? Has their schoolwork declined? Do they make self-critical remarks?
CBS CARES: Any other warning signs that parents should look for to clue them to the possibility that their teenage child is depressive and/or suicidal and may need professional intervention and help?
DR. SHAFFER: The most important warning sign is a change. For example, a youngster who used to enjoy company now spends most of their time at home; a youngster who had a great interest in a sport or a particular activity gives up their interest and it is not replaced by any new one; or a youngster who has always been friendly, amiable, and tolerant becomes easily irritated, critical, and oversensitive to any criticism. Not infrequently, depression is expressed openly, for example, by a youngster who says that they feel desperate, don't see any point in going on, want to commit suicide, etc. Other warning signs of depression are frequently finding reasons to stay away from school and stay at home, the onset of frequent stomachaches or headaches or other bodily complaints in a child who otherwise seems well, or the onset of a very critical approach to their own work or accomplishments or popularity.
Depression can sometimes be felt, even if it is not stated. Parents who have experienced a depression themselves are sometimes the people who are the most sensitive to mood changes in their family. Others might also get a feeling of sadness when they are in the presence of the depressed teenager.
CBS CARES: Can you provide some advice to parents of depressive teens who may need help on how to broach the subject and reach their child in the most credible and effective way?
DR. SHAFFER: Parents are often anxious about how to broach this with a teenager and are sometimes unduly pessimistic. If a teenager feels bad, they will usually welcome an opportunity for a confidential discussion with a specialist. If the teen is determined about not seeing a psychiatrist or psychologist, you could share your concerns with a member of the family or a close friend who is trusted by the teenager and asking them to discuss the matter. A school psychologist or counselor might be able to have a franker discussion with them than you can. Another approach is to offer the teenager a depression questionnaire to fill in. That might allow both of you to get some appreciation of how their thoughts and feelings fit the idea of depression.
In instances where this is very difficult, and if there is a deterioration in school attendance or schoolwork, a strong request, or even demand, by the school that the child be seen for a professional opinion is not usually ignored.
CBS CARES: Is it common that depressed people try to medicate themselves by making excessive use of alcohol and/or drugs? If so, how much does addiction complicate the diagnosis and treatment of depression?
DR. KAHN: About a quarter of people with depression abuse alcohol or other substances, and over half of those with bipolar disorder do the same. These rates far exceed the rates in the general public. Self-medication, trying to feel better, is one cause; sometimes, however, the main problem is the substance abuse, and this often can cause symptoms of depression that get better when the person becomes abstinent and deals with the reasons behind the drug or alcohol use.
CBS CARES: Is lack of self-esteem more a cause or a symptom of depression…is someone with low self-esteem highly vulnerable to depressive states?
DR. KAHN: Low self-esteem can be a cause of depression, but can also be a symptom of depression. It is very interesting to see how someone depressed for many years feels better about him or herself when depression lifts with antidepressants. Assertiveness and self-confidence can often follow effective treatment. For other people, however, self-criticism is a more complex problem that may have originated in feelings of failure early in life, and reversing this self-image in psychotherapy can help alleviate depression.
CBS CARES: Why do some depressed people go on to develop psychotic symptoms?
DR. SHAFFER: There are two types of psychosis, schizophrenia and depression. In a psychotic depression, the patient will usually have delusions or hear voices criticizing them, indicating that they are a bad person or that they have made serious mistakes in the past. Sometimes, but not always, seriously, psychotically depressed individuals will commit suicide, and such thoughts might have been one aspect of their illness.
CBS CARES: How are depression and anxiety related? And can that affect diagnosis?
DR. GLASSMAN: Depression and anxiety can be quite distinct. One is normally related to a sense of loss and the other to danger. However, individuals who suffer excessively from one condition are more likely to experience the other. Often anxiety precedes depression; sometimes people experience marked increases in anxiety as a part of their major depression. If someone experiences markedly increased anxiety in a depressive episode, the anxiety usually abates with improvement in the depression. Anxiety and depression are both moods, and these moods are both regulated by the same area of the brain. In that sense, it is not surprising that they frequently coexist.
CBS CARES: Do depressions sometimes manifest as physical complaints?
DR. MUSKIN: In one study, about 50% of patients' medical complaints were unexplained after medical evaluation. Of this group of patients, about 69% were diagnosed as depressed using carefully done measures. If a very thorough medical evaluation does not reveal a cause for the symptoms, then the physician should strongly consider investigating a psychiatric disorder. Many medical symptoms are not explained after a medical evaluation. This is one indication that the patient might be depressed.
CBS CARES: New York City doctors have started using a routine questionnaire to determine whether a patient is at risk of depression. What is your response to politicians and patient rights groups who argue that such broad testing for mental illnesses may cause over diagnosing and needless treatments?
DR. ROOSE: There are excellent validated routine screening questions that alert
the busy primary care doctor that a patient may have a depression such as the Prime-MD developed by Robert Spitzer. These questionnaires are very sensitive but not specific, i.e. a positive response needs to be followed up with a more comprehensive diagnostic
interview. Screening instruments are very helpful if used properly, which means to screen not to diagnose. The problem is not over-diagnosis of depression but under- diagnosis. There are over 35,000 suicides/year in the US and many of theses result from depression.
30% of people who commit see a doctor on that very day. Better screening for depression can save lives.
CBS CARES: Why would someone who has studied medicine and science for years decide to specialize in the human mind? Is there anything psychologically significant about someone choosing psychiatry as a profession?
DR. SILBERSWEIG: The scientific exploration of the human mind and the application of findings to the medical treatment of those with mental illness represents one of the most exciting frontiers in medical science today. We have unprecedented ability to address questions that were thought not to be amenable to empirical examination just a few years ago. The old stereotypes about psychiatry and psychiatrists no longer hold. There is nothing more or less psychologically significant about a person choosing psychiatry as compared to any other medical specialty.
CBS CARES: In general, are physicians specializing in Internal Medicine trained to diagnose and treat psychiatric disorders?
DR. MUSKIN: Very few training programs in Internal Medicine offer adequate education in the diagnosis and treatment of psychiatric disorders. Thus primary care physicians who wish to be adequately trained need to obtain continuing medical education. They also should have a professional relationship with a psychiatrist with whom they can discuss patients, and, if necessary, obtain consultation when the patient does not have an adequate response to the antidepressant, or requires more psychiatric skill than is reasonable to expect from a primary care physician.
CBS CARES: Do physicians have difficulty raising the possibility of a psychiatric disorder with patients?
DR. MUSKIN: Physicians may be reluctant to broach the subject of a possible psychiatric disorder for fear the patient will feel accused of faking or being "crazy." And sometimes, physicians have negative feelings towards patients for whom the medical work-up is unrevealing. Physicians may find it difficult to educate patients that psychiatric disorders are still medical disorders, sometimes because the physicians themselves are not sufficiently informed or accepting of that reality. Failing to have a supportive and informed discussion with the patient may result in patients feeling labeled as "crazy" or inappropriately stigmatized by a psychiatric diagnosis.
CBS CARES: You just said that physicians sometimes have negative feelings towards patients whose work-ups don't reveal a physical disease. Why is this the case in that diagnostic tests for physical diseases are not infallible and, if the problem is psychological, it's still a medical condition for which the patient needs help?
DR. MUSKIN: Doctors are human. Furthermore, the medical advances of the past 50 years have been remarkable. This leads to an unrealistic expectation that we can diagnose and cure everything. Some doctors fall into that trap and then when the medical work-up is unrevealing they feel that the patient has "fooled them" and has known all along that this was psychological. These doctors also may feel ill-equipped to handle psychiatric disorders.
CBS CARES: Do many physicians have trouble seeing a psychiatric disorder as a medical condition?
DR. MUSKIN: Yes. Many physicians, and members of the public, refuse to accept that psychiatric issues are medical ones and that mental functioning is the result of biological processes. Chest pain from a narrowed coronary vessel and chest pain from hyperventilation secondary to anxiety both feel like chest pain to the patient. One is seen as valid, the other as "all in your head." The belief that we can control all emotional aspects of what we experience is incorrect, but it is harbored even by some physicians who see the patient as responsible for their own condition and symptoms.
CBS CARES: How can this mindset be changed...do you think there needs to be more training and sensitization of physicians about psychiatric disorders so that they don't perceive the problem as the patients' fault? If so, how and where can this training take place?
DR. MUSKIN: Considerable effort goes into training medical students to understand more about the person whom they treat and not see patients as illnesses. Why doesn't it work? Very little of the efforts during medical school continue when the students become physicians. Very few programs teach much about psychiatric disorders. When patients have a psychiatric problem, they call a psychiatrist to take care of it. Thus, when out in practice, how much could a physician know about psychiatric disorders, or how to approach the interface between mental and medical?
There are programs for physicians in practice to learn communication skills. One is the MacArthur Program on Depression. When these skills become part of the requirement for residency programs, and physicians in practice can demonstrate competence with these skills, we will see a change in physicians' behavior.
CBS CARES: Have you had doctors refer patients to you on the basis that there is nothing physically wrong with the patient and that the problem must therefore be psychological... but where your evaluation showed that there in fact was an underlying physical illness and that any psychological components were secondary? If so, what was it about your evaluation that enabled you to see that any anxiety or depression was secondary to a still undiagnosed physical disease, rather than the main illness?
DR. MUSKIN: Yes. Some diagnoses can take awhile or require persistence to manifest themselves. What physicians can and should offer their patients-and this is very important-is the willingness not to get locked into one point of view, not to believe that diagnostic procedures are perfect and not to abandon their patient, even if they don't know what to do right then. Here are two examples where patients were referred to me, with the assumption by the physician that the symptoms were primarily driven by a psychiatric condition:
1. I was sent a woman who complained of palpitations, feeling dizzy, and chest pain. Her cardiologist had tried everything to evaluate this complaint. Nothing had turned up and the conclusion was that this was psychosomatic. The patient had a rocky relationship with her family. Though she denied abuse, everyone involved with her had the sense she had been abused as a child. She insisted she had a medical condition, but went along with the psychiatric treatment. She could not work, but her employer very much wanted her back, as she had been so successful. Out of frustration with all of us she went to another cardiologist as she felt her original doctor could only see her as someone who had a psychiatric disorder. This second cardiologist suggested a risky procedure to diagnose what might be wrong with the patient's heart. She proceeded with the test, which revealed a disorder that was cured by a medical procedure.
2. A patient I treated had serious cardiac disease, but also had significant psychiatric problems. His continued complaints of chest pain resulted in many evaluations that demonstrated his cardiac disease but could not explain the chest pain. He noted that he did not have pain when exerting himself, unlike his regular chest pain. His doctors told him it was anxiety, but he felt that it was the pain making him anxious not the other way around. We talked about his pain, and his anxiety, but little changed. One time I asked him if there was anything about his medical conditions that he had not told me as I was trying to figure out what was wrong with him. He mentioned he used bronchial inhalers for his asthma, not something he had ever thought to mention, as his asthma never bothered him. He had never been told to use a spacer or rinse his mouth out after using the steroid inhaler. This led me to wonder if he had a fungal infection of his esophagus, which can be painful. He pursued this, leading to a diagnosis, and then treatment. The information was always there, but remained hidden until someone thought to ask the right question.
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