The doctor confirms what you already know. Now what?

by John McManamy


DEPRESSION isn't the word for it. We're talking about a condition that can take over your mind, rob you of your dignity, deprive you of all the joyful offerings of life, and leave you nose down in two inches of water, feeling totally abandoned by man and God. Brain crash is more like it, of the inside of the head throwing up error codes and sucking up energy and failing to accomplish even the most simple of tasks, reducing one to a state of utter despair, a walking corpse perhaps on the way to becoming a real one.William Styron, the late Pulitzer Prize-winning author, in his memoir of depression, "Darkness Visible," had this to say:

... all sense of hope had vanished, along with the idea of a futurity; my brain, in thrall to its outlaw hormones, had become less an organ of thought than an instrument registering, minute by minute, varying degrees of its own suffering.

So, what, exactly, are we talking about? Ah, that's the rub. Maybe your brain didn't crash, after all. Maybe it simply refused to start, like a car with a dead battery. Or maybe the exact opposite - maybe your brain refuses to shut down.

The Diagnostic and Statistical Manual for Psychiatric Disorders, Fifth Edition (DSM-5), the diagnostic Bible put out by the American Psychiatric Association, at best offers an approximation of reality and at worst a mythological view of what is going on inside our heads.

The Depression Symptom Check-List

In its criteria for major depression, the DSM lists EITHER feeling depressed most of the time for two weeks OR abnormal loss of interest or pleasure most of the time for two weeks. The symptoms must not be attributable to something else (such as bereavement, substance use, or a medical condition). These are the first of two symptoms on a nine-symptom checklist, and at least ONE has to be filled in. No check-mark, no depression.

This dichotomy effectively divides depression into an either-or (or both-and) choice of too much emotion (such as exaggerated sadness) on one hand or lack of emotion on the other. So far, so good. If the DSM kept this dichotomy going, clinicians might actually be encouraged to find out what is really wrong with you. Instead, the DSM goes completely off-track.



There are seven more symptoms on the nine-symptom check-list. After checking off one (or both) of the first two, four of the next seven (slightly edited) must be checked (again, all over at least two weeks and not attributable to other stuff):

  • Appetite or weight disturbance, either weight loss or weight gain.
  • Sleep disturbance, either abnormal insomnia or abnormal hypersomnia.
  • Activity (psychomotor) disturbance, either abnormal agitation or abnormal slowing (observable by others).
  • Abnormal fatigue or loss of energy.
  • Abnormal self-reproach or inappropriate guilt.
  • Abnormal poor concentration or indecisiveness.
  • Abnormal morbid thoughts of death (not just fear of dying) or suicide.

Reviewing the Math

Nine symptoms in all, five symptoms must be checked. At least one symptom must be checked from the first two symptoms listed. Now that you know this, it is best to forget it. Diagnosis by counting is a totally absurd, and often very dangerous, proposition. When it works, we arrive at a very rough indicator of what may be wrong with us. Too often, the exercise is wholly misleading.




Analyzing the Depression Check-List

The depression check-list dates from the DSM-III of 1980, and is basically a camel designed by committee. To give you one example:

Four of the symptoms can be considered physical in nature. So imagine, your doctor checks off "depressed mood most of the day" (whatever that may mean) PLUS weight gain, hypersomnia, psychomotor slowing, and fatigue. What does that tell us?

For one, it tells us nothing about our state of mind (stressed? overwhelmed? feeling empty?) Nor do we get a good read on our emotions (blunted? over-sensitive? fearful? not caring?). Nor do we get a sense of how we're thinking (over-ruminating? unable to put two thoughts together?).

Only four symptoms actually probe for state of mind, and these hardly contribute to a complete picture. But for the purposes of the DSM it doesn't matter. Five symptoms, and - voila! - we are "depressed."

Look at those same four physical symptoms again. Granted, they don't tell us what is going on inside our head; nevertheless they represent fairly good markers of the brain in a state of distress. But what kind of distress? Three of the symptoms are presented as sets of opposites, too much or too little - appetite, sleep, activity. Obviously, someone who can't eat and sleep and is pacing about like an over-cranked wind-up toy is in very different mental shape than someone who can't stop eating and sleeping and can't move (and almost certainly has no energy).

Yet - get this - according to the DSM, both these individuals have the exact same condition. One is exhibiting outward signs of being an over-ruminating fearful nervous wreck, the other is showing signs of needing to be on life-support. Yet a doctor - with the full authority of psychiatry's diagnostic Bible - will diagnose each one with "depression" and send both out the door with the same prescription.

How crazy is that?




Needless to say, way too much attention is paid to the symptom check-list. You will find it replicated on every depression website, book, and brochure as if God had handed it down to Moses (and trust me, the person responsible for this check-list - the late Robert Spitzer - did have a God complex, but that's another story).

Far more significant than the symptom check-list is the little-noticed DSM indicator of "functionality." Above the symptom check-list, the DSM notes that the symptoms "must represent a change from previous functioning," and down below we read that these symptoms must "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning."

In other words, if you are depressed, then performing your day job is going to be very problematic. So is maintaining relationships. So is being at peace (or at least in a state of cease-fire) with yourself. We need our wits about us merely to survive in this world. But - gradually or suddenly - it's as if our brains have quit on us. We can't cope, we can't function.

Depression is a Stone Age condition, a very modern illness. There is no allowance in a post-industrial service economy for an individual who is not on his or her game. A teacher keeping 30 kids under control is fully dependent on an operational brain. A journalist racing to meet a deadline needs to do it with all his neurons firing. A salesperson requires every chunk of available grey matter to make it look as if she is glad to see you.

On top of that, these same individuals require full processing speed to manage their personal lives and family obligations. So much to do, so little time to do it in. Maybe we can write off one bad day. Two bad days is going to get the attention of people who rely on you. Two weeks of bad days is catastrophic.

Restoring Us Back to "Normal"

In this sense, depression is an "episodic" illness. Indeed, the DSM depression check-list is entitled, "Major Depressive Episode." The actual illness, "Major Depressive Disorder," requires at least one episode lasting at least two weeks. The assumption is that prior to the episode, you were at least in some acceptable state of functioning. Your life may have been a train-wreck, you may have been voted Existential Person of the Year for the eleventh year running, but for psychiatric purposes you were considered normal.

Psychiatry is all about restoring us back to our "normal" baseline, to our previous state of angst and misery, if you like, before our lives started to fall apart on us. The assumption is that once we rebound from our episode - once our brains are back online - then we have the resources to deal with our barely manageable lives anyway we see fit.

I challenge this assumption throughout this site (particularly in the Recovery section). Nevertheless, it is foolhardy to belittle where psychiatry is coming from, especially in the face of one of the worst illnesses known to humankind. According to the World Health Organization, major depressive disorder is the leading cause of disability in the US and established market economies worldwide. Approximately 10 million American adults, or about 5.0 percent of the US. population age 18 are afflicted in any given year. About 30,000 Americans and one-million people world-wide take their lives each year, higher than homicide rates, about equal to the AIDS toll.

In my book, Living Well with Depression and Bipolar Disorder, I write:

It was only a question of working up the courage. But the way things were going, courage would no longer enter into it. Just a little deeper into the Mount Everest Death Zone, I knew, and it wouldn't be a matter of me committing the act. The act, instead, would commit me. The rope would tie its own noose, the pond's frigid waters would warmly embrace me, the bridge would obligingly throw me off ...

But at the last minute I chickened out. I chickened out. That's how I felt at the time. I stood in my mother's kitchen, back to her, hands clutching the sink, and called out for help. The total illogic of the decision stunned me. It made no sense to a person in my condition. I had chosen life over death.

I don't kid myself. I will always be an emergency room case waiting to happen. Once you have emerged from the Death Zone and lived to tell the tale you are never the same. On one hand I am amazed at my strength in surviving the ordeal, on the other I am humbled by the fact that I am no more than a leaf in a tornado to my condition.

Bottom Line

Basically, we KNOW when we are depressed. We SENSE something is wrong. We literally FEEL our brains quitting on us. At the same time, though, we tend to be in denial. We think that if only we were stronger, if only we had the strength of character to snap out of it, we will be fine. In the meantime, our depression-fueled inner mother-in-law is telling us that we only have ourselves to blame.

Generally, it's only when our lives have fallen apart that we seek help, but even then the denial factor is strong. Typically, we will complain to our GPs of physical symptoms. A smart GP will take the time to probe for mental symptoms, but who has time?

Eventually, though, a doctor or psychiatrist will make the obvious call - depression. At last, you have a name for it, the source of all your woes. Or do you?

As I said at the very beginning: "Depression isn't the word for it." The term is merely a medical confirmation that your brain has lost - at least for the time being - its capacity to fully handle whatever life may be throwing your way. Now that you know that you are "depressed," you need to find out what is really going on.

Keep reading: Figuring Out Depression.

This article is the first in a four-part series.

Reviewed June 16, 2016


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