Good grief — when is depression a disorder?
Published in Health News and Evidence
Date published: About this date
The publication of the DSM-5 manual by the American Psychiatric Association has prompted much comment and some criticism, especially about the perception that certain aspects of the manual may lead to the medicalisation of normal human emotion or lead to overdiagnosis with potential overtreatment.
It is not clear what the publication of DSM-5 means for the diagnosis and management of mood disorders in primary care. Scoring systems used in the DSM-5 may have little applicability in busy practices where depression rarely presents with classic symptoms.
Overall the DSM-5 would appear to offer few changes to the management of depression in primary care. The use of Australian–based guidelines is recommended.
- Is this person distressed and/or depressed?
Look for a change from usual mood, behaviour or demeanour, loss of joy and interest in things, crying or unusual moods (including irritability).1
- How severe is the depression?
Assess the presence of symptoms of depression, level of functional impairment and always directly ask about suicidal ideation and intent.1,2
- How long and how much of the time have the symptoms been present?
A diagnosis of depression requires that the symptoms persist for several weeks (probably more than 2 weeks) and are pervasive (present in all situations).1,2
Before starting treatment
- Exclude other causes and evaluate history
Seek an explanation for the distress (e.g. grief) and exclude treatable causes such as an alcohol or drug problem, other psychiatric conditions including anxiety or bipolar disorder, adverse effects of medication or active medical conditions (e.g. hypothyroidism).1,3
- Evaluate if there is a past or family history of depression1,2
- Assess signs and symptoms
Consider using a structured assessment tool to document extent and nature of signs and symptoms; follow up to assess treatment response.1,3
- Review medicines
Review current medications (including non-prescription) and assess potential for interaction.3
- Stepped care
Use a stepped approach to match the severity of depression with the response to intervention.1,2
- Non-drug first
Use non-drug treatments first in subthreshold or mild depression rather than antidepressants.1–4
- Offer comfort and reassurance for patients reacting to grief
Offer comfort, listening and reassurance, counsel and mobilise social support and promote problem-solving for grief reactions including mild–moderate–severe mood disturbance that is understandable as a reaction to the loss.1
- Consider psychotherapy
Always consider psychotherapy (e.g. cognitive behavioural therapy) as it augments drug treatment and may be effective in mild-to-moderate depression.3
Refer to specialist care in cases of severe depression where the risk of self harm is high.2,3
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was recently published by the American Psychiatric Association.5 While many hoped the latest edition would reflect advances in biological and laboratory tests that could confirm a diagnosis, the translation of scientific advances to practice is not evident.6 Over 10 years in the making, the launch of DSM-5 has not been without controversy.7,8
Medicalising grief — the bereavement exclusion
A significant focus of the debate has centred on the medicalisation of human emotions, such as grief, given the removal of bereavement as an exclusion criteria for major depressive disorder.9–11 These changes have been criticised as encouraging a diagnosis in healthy people and for being unhelpful to clinicians dealing with the dilemma of a bereaved patient with mild depressive symptoms.12 The changes have also been said to encourage use of antidepressants in people who do not need them.12
Utility in primary care
The recognition, diagnosis and management of depression and mood disorders in primary care are complicated by high case loads and time pressures. Diagnostic tools and treatment guidelines like the DSM-5 sometimes fail to take into account the realities of primary practice and may not provide health professionals with the pragmatic information they require to diagnose and treat their patients effectively. This is not a new problem. For decades classification systems have contributed to psychiatric research but have not been widely used in primary care settings.13
Despite a refreshed edition, the challenge to develop diagnostic systems that are useful in, for example, a busy general practice, remains unmet.14 This begs the question, how is depression recognised in primary care?
A common but under-recognised condition
GPs manage most depression
According to the 2011–2012 Australian Health Survey, about 10% of the population is affected by depression.15 This leads to 5.4 million consultations with GPs, making depression among the top six chronic problems managed by GPs and the most common cause of clinical treatments and referrals.16 While most depression is treated in primary care,17 only half the depressed people who present there will be recognised.18
Depression is however, an important and common condition that has serious negative consequences on the health and welfare of the sufferer and their families. It is important to recognise early, diagnose accurately and treat using the best evidence.
The problem of under-recognition
In primary care, diagnosing depression is not straightforward. A recent pooled analysis of over 50,000 people in primary care showed that depression is both under- and over-diagnosed,19 and that:
- only half of depressed people are recognised as such
- 20% of non-depressed individuals are misdiagnosed
- misdiagnoses outnumber missed cases.19
This can be partially attributed to difficulties in differentiating major depressive disorder from sub-threshold (also known as sub-clinical or sub-syndromal) depression or other mixed mood states.19,20 The prevalence of sub-threshold depression in primary care settings ranges from 3–10%.21
It is a commonly held view that most unrecognised cases represent less severe depression that is eventually picked up in follow up consultations.22 This is supported by findings from New Zealand where under-recognition was related to how much contact patients had with the GP.23 However, early recognition of the condition is important because depression is associated with ongoing disability and premature death.22
Current Australian guidelines refer to DSM24 or International Classification of Diseases (ICD) criteria1 or both.4 Under both classification systems diagnoses are made based largely on symptom counts — for example five symptoms are required for a major depressive disorder diagnosis while any fewer (e.g. 2–4 symptoms) is defined as sub-threshold or minor depression.5 However, international guidelines caution against relying on symptom counts alone.2
GPs consider the context of depression
Few patients present as simple cases that can be described by standard classifications.13 For example, anxiety symptoms can be prominent in depressive disorders. Furthermore, many GPs doubt the validity of classification systems and prefer to rely on a process that draws on experience-based problem solving.25,26 An Australian study found that while GPs recognise symptoms that overlap with classification systems such as crying, loss of interest, disturbed sleep and impaired function,25 they also recognise a model that contextualises depression as a reaction to circumstances,25,26 something that is missing from contemporary classifications.
Ruling out somatic causes
In primary care, depression is frequently comorbid with other medical conditions and people may emphasise non-specific somatic symptoms such as headache, nausea, musculoskeletal pain or prolonged fatigue.22 Depression is less likely to be recognised in these patients.22 Accordingly one strategy used in primary care to help with the diagnosis of depression is to rule out somatic causes for symptoms.25,26 A comprehensive history, together with the GP’s knowledge of the person, will help to contextualise depressive symptoms and may lead to a watchful waiting approach to diagnosis.26
Differentiating between depression and grief involving intense sadness is challenging for many clinicians.12,27 This is because normal grieving in response to a major loss (e.g. bereavement, financial ruin or natural disasters) as well as complicated grief, frequently presents with symptoms that are typical of depression, such as sadness, tearfulness, insomnia and decreased appetite.12,27,28
Bereavement is a severe stressor that can also trigger the onset of a physical or mental disorder or interfere with natural healing.28 Acute grief is a normal response to loss and symptoms need not imply underlying pathology, but grief can be complicated such that intensity of symptoms is heightened and their duration prolonged.28
Because the experience of grief is so variable, there is no agreed duration defining aberrant grief; there is general agreement that by at least 6 months most of the emotional distress abates and a bereaved person is re-engaged in daily life.10,29 Under DSM-5, symptoms must persist for at least 12 months to be labelled as a disorder.30
Compared with normal grief, complicated grief is associated with prolonged distress and disability, negative health outcomes and suicidal ideation.28 Table 1 outlines some key differences between major depressive disorder and acute grief.
Table 1. Differences between depression and bereavement-related grief29
|Major depressive disorder||Acute grief
|Pervasive loss of interest or pleasure||Loss of interest or pleasure related to missing loved one|
|Pervasive dysphoric mood across situations||Pangs of emotion triggered by reminders of loss|
|Preoccupation with low self esteem; general sense of guilt or shame||Preoccupation with the deceased; guilt and self blame focussed on death|
|General withdrawal from activities and people||Avoidance of activities, situations and people because of the death|
|Intrusive images are not prominent||Intrusive images of the deceased are common|
|Yearning and longing not usually seen||Yearning and longing are frequent|
However, as with the distinction between normal sadness and clinical depression in primary care, 'perhaps it does not matter all that much’ because 'a person in distress who comes for help needs help'.1 What is important is selecting the appropriate form of help.
For independent information on treating depression see the following NPS MedicineWise resources:
Dr Chris Moodie
A practising GP who specialises in youth mental health.
Dr Moodie reviewed this article.
'The 5th edition of the DSM has, if anything, shifted more toward a tool used by the insurance and legal professions, and less of a useful tool for the clinician, or indeed the patient. Nevertheless, all medical practitioners will need to be familiar with the changes in the new classification, some subtle, some not so subtle.’
- Beyond Blue Ltd. beyondblue guide to the management of depression in primary care. 2010. https://www.bspg.com.au/dam/bsg/product?client=BEYONDBLUE&prodid=BL/0484&type=file (accessed 17 June 2013).
- National Institute for Health and Clinical Excellence. Depression in adults: The treatment and management of depression in adults. NICE clinical guideline 90, 2009. http://publications.nice.org.uk/depression-in-adults-cg90 (accessed 17 June 2013).
- Rossie S (ed). Australian Medicines Handbook. Chapter 18: Psychotropic drugs, 18.1 Antidepressants, 2013.
- Therapeutic Guidelines Limited. eTG Complete. Psychotropic 2013. http://etg.hcn.com.au (accessed 17 June 2013).
- Diagnostic and statistical manual of mental disorders. 5th edn. Washington DC: American Psychiatric Association, 2013.
- Roehr B. American Psychiatric Association explains DSM-5. BMJ 2013;346:f3591. [PubMed]
- Gornall J. DSM-5: a fatal diagnosis? BMJ 2013;346:f3256. [PubMed]
- Watts G. Critics attack DSM-5 for overmedicalising normal human behaviour. BMJ 2012;344:e1020. [PubMed]
- Wakefield JC. DSM-5 grief scorecard: Assessment and outcomes of proposals to pathologize grief. World Psychiatry 2013;12:171–3. [PubMed]
- Bryant RA. Is pathological grief lasting more than 12 months grief or depression? Curr Opin Psychiatry 2013;26:41–6. [PubMed]
- Parker G. Opening Pandora's box: how DSM-5 is coming to grief. Acta Psychiatr Scand 2013;128:88–91. [PubMed]
- Friedman RA. Grief, depression, and the DSM-5. N Engl J Med 2012;366:1855–7. [PubMed]
- Hickie IB. Primary care psychiatry is not specialist psychiatry in general practice. Med J Aust 1999;170:171–3. [PubMed]
- Hickie IB, Scott J, Hermens DF, et al. Clinical classification in mental health at the cross-roads: which direction next? BMC Med 2013;11:125. [PubMed]
- Australian Bureau of Statistics. Australian Health Survey: First Results, 2011–12. 2012. http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/1680ECA402368CCFCA257AC90015AA4E/$File/4364.0.55.001.pdf
- Britt H MG, Henderson J, Charles J, Valenti L, Harrison C, Bayram C, Zhang C, Pollack AJ, O'Halloran J, Pan Y. General practice activity in Australia 2011–12. Family Medicine Research Centre, 2012. http://hdl.handle.net/2123/8675 (accessed 26 March 2013).
- Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 2007;370:841–50. [PubMed]
- Hickie IB, Davenport TA, Naismith SL, et al. Treatment of common mental disorders in Australian general practice. Med J Aust 2001;175 Suppl:S25–30. [PubMed]
- Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009;374:609–19. [PubMed]
- Abramowitz S, Ani C. GPs good at ruling out depression in primary care, but false positives common. Evid Based Med 2010;15:29–30. [PubMed]
- Rodriguez MR, Nuevo R, Chatterji S, et al. Definitions and factors associated with subthreshold depressive conditions: a systematic review. BMC Psychiatry 2012;12:181. [PubMed]
- Wilhelm KA, Finch AW, Davenport TA, et al. What can alert the general practitioner to people whose common mental health problems are unrecognised? Med J Aust 2008;188:S114–8. [PubMed]
- Bushnell J. Frequency of consultations and general practitioner recognition of psychological symptoms. Br J Gen Pract 2004;54:838–43. [PubMed]
- Ellis P. Australian and New Zealand clinical practice guidelines for the treatment of depression. Aust N Z J Psychiatry 2004;38:389–407. [PubMed]
- Clarke DM, Cook K, Smith GC, et al. What do general practitioners think depression is? A taxonomy of distress and depression for general practice. Med J Aust 2008;188:S110–3. [PubMed]
- Schumann I, Schneider A, Kantert C, et al. Physicians' attitudes, diagnostic process and barriers regarding depression diagnosis in primary care: a systematic review of qualitative studies. Fam Pract 2012;29:255–63. [PubMed]
- Wakefield JC, Schmitz MF. When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds. World Psychiatry 2013;12:44–52. [PubMed]
- Shear MK, Simon N, Wall M, et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety 2011;28:103–17. [PubMed]
- Shear MK. Grief and mourning gone awry: pathway and course of complicated grief. Dialogues Clin Neurosci 2012;14:119–28. [PubMed]
- American Psychiatric Association. Highlights of changes from DSM-IV-TR to DSM-5. American Psychiatric Publishing, 2013. http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf (accessed 13 June 2013).