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The Sunday Times
Dr Thomas Stuttaford
Is depression being used to diagnose too many people?
Depression is the description of a symptom that has many potential causes, each of which must be analysed before a true diagnosis can be reached. To say that a person’s troubles are the result of depression doesn’t tell the whole story. The term is used too often and as a diagnosis without any qualification it is to all intents and purposes useless.
Don’t many doctors tell a patient that they are suffering from depression and also include it on their medical certificates?
Yes. But it is hoped that when a doctor uses the term depression to describe someone’s psychiatric problems it is only as shorthand. It may be that they have already described the type of depression that their patient is suffering from and to put it all on a certificate would be impossibly cumbersome. Shorthand may also be deliberately vague so as to preserve the patient’s confidentiality.
Are there other organisations and professions that use the term depression in such an ill-defined way as doctors?
Yes. Unfortunately coroners, social workers, the police and the media all use the label depression loosely. Frequently there are reports in the papers that someone is suffering from depression without any attempt made to describe what type of depression it is. If this has resulted in suicide, homicide, divorce or job loss it is not only misleading but can be very disturbing to someone else who has a condition in which one of the symptoms is being depressed but can easily be treated.
Surely the true nature of a person’s psychiatric or psychological problem is revealed by a broadcast or written interview?
Only when the interviewer understands the subject. Many of the people who appear on radio or television because they are allegedly suffering from depression, are often not truly depressed (as the term would be understood by a doctor). Rather they may be simply fed up, feel incapable of dealing with their lives or be suffering from one of a great many personality disorders.
Does this mean that these people cannot be helped?
Nearly everyone can be helped by kindly understanding and the devotion of time to their difficulties. However there is no pill or easy form of psychotherapy that will help them to cope. They need support. As modern life becomes more complex, and as television spreads awareness of the comfort and luxury that more fortunate people enjoy, the patient’s own difficulties are highlighted.
How are those people who are only incapable of coping, but not depressed in a clinical way described on medical certificates?
Although they may not be suffering from any form of definable clinical depression they are miserable and dispirited. The busy doctor, who has only one line to put his or her diagnosis on a patient’s certificate to explain their inability to work, will write “depression”. In doing so he will help to increase the confusion that surrounds mental health statistics and the conclusions drawn from them.
Does the imprecise use of the term depression have other disadvantages?
It reduces the likelihood of an early diagnosis in patients suffering from depressive states. They may often respond quickly to medical treatment but nontreatment may cause untold misery even death.
Has this problem always existed?
In the past one type of illness was referred to as endogenous depression because it could occur without any external triggering factor. The patient developed clear-cut symptoms that affected their mood. Unfortunately it didn’t describe in any way how severely the patient was suffering and was therefore abandoned. It was and still is a joy to treat this large and important group of patients. Once they have been persuaded that they are suffering from a biochemical abnormality of their central nervous system that can be corrected by pills there is a good chance that their personality will be restored to normal, or near normal, within a few weeks. Treatment with antidepressants, usually the SSRIs (also known as the 5HT reuptake inhibitors) may have to be continued for many months or longer.
Are there any serious consequences of SSRI antidepressant treatment?
All potent drugs have important side-effects. The chief danger of SSRIs, which in general are very safe, is that they are given to the wrong patient. The disasters recorded are not so much disasters from the side-effects of the pill swallowed but a sequel of a sloppy diagnosis when the true nature of the depression affecting the patient hasn’t been analysed.
One of the most potentially dangerous mistakes is to confuse what used to be known as endogenous depression with the depressed phase of a patient who is manic depressive (now known as bipolar). Ordinary antidepressants, when used alone to treat a depressed patient who is bipolar, may precipitate violence, aggression, suicide or wildly inappropriate behaviour.
Do depressive illnesses affect all classes and types of people or only the inadequate?
Depression can be a symptom of troubles that could affect anyone. The obsessionally hard working, striving type A personality or the aesthetic genius are rather more likely to suffer than the straightforward uncomplicated farmer or soldier. However the farmer whose milk is worthless, and the soldier who is unable to achieve some degree of attachment may also crack. Courage is finite and so is the resistance to disaster.
No existence is more demanding than the upper reaches of commerce, industry, finance or the media. Because many potentially depressed patients suffering from an affective disorder are hyper-conscientious workaholics they frequently reach the top of their profession. Those with a straightforward depressed mood may not realise the true diagnosis and are likely to be loath to admit any inadequacy or weakness, especially a mental one. The chairman of one finance house who was a true depressive used to see me every two or three years with one physical symptom or another. “Doctor, I know that the TB I thought I was suffering from two years ago turned out to be related to my mood, but I am now certain that the chest pain I am getting is angina” was a typical start to one of our consultations. Three weeks of treatment with an SSRI drug and his enthusiasm returned. Hopelessness was banished and with it the patient’s chest pain, cough, back troubles or whatever.
What happens if a patient with bipolar disease is seen by a doctor in a depressed phase and the doctor doesn’t realise this but assumes that he is suffering from some more straightforward form of depression?
Disaster can follow. A bipolar depressed patient may be precipitated into mania. He or she can become violent, suicidal or homicidal. These patients must have their psychotic symptoms alleviated as well as their depressed state lifted. Whatever other drugs are prescribed they will need mood stabilisers or atypical anti-psychotics.
As well as the major disasters there are relatively minor ones too. One king of industry given an antidepressant to help him to stop smoking developed acute mania and beat up his second-in-command. The chairman of another company who never saw a doctor but had bipolar moods became so unreliable that another director had to be delegated to follow him around to countermand his more lunatic schemes. A third was sacked before he had been referred to the firm’s doctor but when he was seen the true diagnosis was mania rather than alcoholism . Obsessive stress reveals psychiatric symptoms that have previously been concealed.