Monday, March 14, 2011

The Dreaded DSM Depression Check-List

As part of my mcmanweb overhaul, I have just started writing new articles on depression to replace the old ones on the site. Following is an extract from an article-in-progress:

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 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 someone who can't stop eating and sleeping and can't move (and almost certainly has no energy).

Yet - get this - according 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?


Gledwood said...

Hi, I've followed you for a long time and you always have insightful stuff to say about that lovely Diagnostic and Statistical Manual.

The tick-box approach that you so hate is what people love so very much about the DSM. That's surely why the more regimented DSM criteria tend to be rolled out far more frequently than the less-bulletpointed WHO's ICD-10. I happen to have a mental illness that is diagnosed markedly differently in the USA and Europe (in America I might well be bipolar, here in London I'm schizoaffective).

You say the DSM would consider retarded depression and agitated depression the same, but no psychiatrist would. Neither would any patient. My depressions aren't as extreme as my manias and they fit the retarded oversleeping pattern. I can't think of anything more horrifying than being severely agitated and severely depressed. I've only experienced this when I tried to stop self-medicating (with heroin of all things) and went into cold turkey. Contrary to the image you may have of somebody writhing around in bed, I was up and about, unable to keep still for more than a couple of seconds and depressed and suicidal. Yet I felt so hyped up my thought process began to run away from me. So I met the diagnostic criteria for a mixed state, except of course I was dtoxing from a drug so that doesn't count towards diagnosis of a bipolar disorder. I remember how horrified I was afterwards when I found out by accident what a mixed mood episode was, and realized I'd gone into one. After a week I went straight back to London and heroin and a six-week depression that not even heroin could disguise or shift.

Agitated Depression is the all time pits!

Great post as ever. Why don't you mention the ICD-10 very much? Is it because you're an American in America? Even here the DSM is mroe widely discussed amongst patients than the ICD-10 ...

Willa Goodfellow said...

I have been thinking lately of the symptom list for diagnosing "Fever Disorder" -- You'd have to have either fever and/or fatigue and four others: constipation OR diarrhea; inflated OR deflated white blood cell count; pallid OR florid complexion; dry OR sweaty skin; sore throat, abdominal pain; tenderness of body part; dizziness; nasal discharge.

And I'll bet that the success rate of antibiotics would less than impressive, unless you kept trying...

John McManamy said...

Hey, Gledwood. Great comments. This is why I love my job. You hit on a number of very interesting points, namely"

1. People love the DSM check-list. You're absolutely right, which is why check-lists are so dangerous. But if we must have a check-list, let's make it an accurate one that tells us what is really going on. On mcmanweb, I came up with my own list, which is admittedly confusing but shows what needs to be done:

I'd be interest4ed in your comments.

2. You're dead right. I should comment more on the ICD. I think even if I were European living in Europe I'd be focusing on the DSM, as it has become the de facto bible worldwide. But, yes, I should bring up the ICD more.

Keep posting ... :)

John McManamy said...

Hey, Willa. Is your "fever disorder" the same as my "runny nose disease"? It looks like you've reduced my entire disease (nasal discharge) to a mere symptom of your disorder.

In MY disease, it is "fever" that is the mere symptom.

Seriously, this is what it is like with depression and sleep, where sleep is both a symptom of depression plus a bunch of disorders in its own right.

Naturally we're going to feel depressed if our sleep is messed up and naturally our sleep is going to be messed up if we're depressed.

Then there's all the other crap (oops, diarrhea).

And every med is a good med if it is treating the right condition. Maybe one day we'll find the right condition for using an antidepressant. :)

Anonymous said...

Re: "Seriously, this is what it is like with depression and sleep, where sleep is both a symptom of depression plus a bunch of disorders in its own right."

And then sleep disturbances (or, more accurately, sleep problems so bad they're ruining your life) can also be caused by the meds you're taking for depression, either alone or in a drug-drug interaction, or be "residual symptoms".

Great column.

Anonymous said...

A little bit off-topic, except relevant to the "we all get the same prescription no matter the symptoms" comment :

I have recently shifted my focus from "what can be done for atypical depressive features" to "what do these drugs actually do"?

This, in turn, has led me to start looking into the psycho-neuro-pharmacology side of things. I'm finding it very interesting -- I'm no doctor, but already I'm seeing stuff that helps me begin to understand why (or at least one of the whys) my son might be tired and sleepy all the time, and which drugs he should probably stay away from. And to get some clues about drug-drug interactions.

As a layperson, and novice, I wanted info that wasn't too technical but still covered all the basics. I'm currently reading through all the articles (free) at this website:

John, have you looked at this side of things?

John McManamy said...

Hi, Anonymous1. Exactly. Treating depression is a crapshoot, so we don't know in advance how an antidepressant will work on someone. But if it is messing up their sleep then it is going to mess up their depression. Messed up sleep is not a mere side effect anyone should have to put up with. This is a severe drug reaction that may make your depression a lot worse.

John McManamy said...

Hey, Anonymous2. I've been thinking along these lines. Depression is extremely complex and we're probably talking about dozens of illness and not just one. But as a rough guide we can break down depression into "vegetative" and "agitated."

So whether we are talking meds, supplements, or yoga we are employing similar strategies - energizers for the vegetative depressions, relaxants for the agitated ones. Thus:


Energy/pleasure/concentration - something safe to boot up the dopamine system (maybe on an as-needed basis). Which means going off-label and working with a smart doc.

Agitation/anxiety - Perhaps an SSRI, maybe an anxiety med (as needed) maybe a mood stabilizer.

Supplements: Energizing supplements (but beware of energy drinks) for vegetative depressions. Calming supplements (such as kava, maybe GABA) for agitation/anxiety.

Yoga: Breathing exercises and postures to energize (such as bellows breathing). Calming breathing and postures for agitation/anxiety (such as inhaling slowly through one nostril and exhaling slowly out the other).

It's still going to be a crap-shoot figuring out what works, but a far less random one.

Anonymous said...

John, I'm the same "Anonymous" who did the two posts above. An interesting thing has just happened that I wanted to share:

Background: son has had recurring major atypical depression for about 10 years, with one or two hypo episodes back in the beginning. Nothing helped with fatigue, hypersomnia, lack of energy -- the usual lab tests showed him to fit as a fiddle. But he still felt something wasn't right.

Anyway, this week he saw an endocrinologist for the first time and was found to have low vitamin B12 levels. The nurse who called him with the results said they were a bit puzzled by the labs, as they don't see this condition in young people, or people who aren't vegetarians.

But here's the thing: my late mother was diagnosed with (very serious, i.e. fatal if untreated) pernicious anemia in the mid-70s. She was in her early 50s at the time. This is an immune disease which prevents the absorption of Vitamin B12. She had to have monthly shots for the rest of her life. The endo. doesn't know this yet -- no doctor knew it as they never asked, and I never knew it was relevent to my son's condition or was genetic.

Now, low Vitamin B12 doesn't necessarily mean pernicious anemia (that's the next test for my son). But if the Vitamin B12 level is low, that has to be taken care of as there can be serious long-term consequences.

Here's something I learned that has wide-spread relevance when I started reading up on this:

Anti-depressant meds. don't work as well if your B12 levels, and folate levels, are on the low side. Now, what is "the low side" would be determined by your doctor, following a cheap blood test. Presumably a minor case could be resolved with vitamin supplements, and more serious cases with the shots. Then the ADs might work better!

My son had never had his B12 levels checked until this week. It's just assumed that this is a problem of malnutrition, or in the geriatric population set, so nobody tests for it.