Depression: Symptom or Diagnosis?

One of the first things one learns in the clinical part of medical school – the time when one sees actual patients – is the difference between symptoms and signs, the latter sometimes being called clinical signs.

A symptom is what the patient complains of. It might be pain, a cough, skin itching, feeling sick, etc. In other words, symptoms are subjective experiences. For example, a patient may say, ‘I feel a pain in my leg’ or ‘I have an itch in my groin.’ Similarly, patients may say they feel unhappy, sad, or depressed.

A sign is what the doctor observes, such as a skin rash, a lump or swelling felt in the abdomen, a raised body temperature, abnormal heart or lung sounds heard through a stethoscope, among many others.

Symptoms may have multiple causes, and the doctor consulted needs to try to discover which  applies in a particular case. The way this is done can be set out thus:

            Symptoms + Signs + Tests (if needed) = Diagnosis

Therefore, by definition a symptom cannot be a diagnosis. However, in the field of psychiatry this seems to have been forgotten. The feeling or emotion of depression is itself regarded as a diagnosis, and additional symptoms are sought to assess its degree or type. So we have the confused situation where you can have symptoms of a symptom. Of course, a patient who feels depressed often has additional problems, such as sleeping difficulties, tiredness, lack of enjoyment in previously pleasurable activities, thoughts of suicide, etc.

Such additional symptoms may be assessed by their number and duration, but this is entirely subjective and arbitrary. It is typically what we find in the WHO approach as set out in the International Classification of Diseases (ICD), particularly in that part which deals with what they call Mental and Behavioural Disorders. The American system, as expounded in a 1,000-page tome, the Diagnostic and Statistical Manual of Mental Disorders (DSM), is similar.

The ICD at least does admit:

Disorder’ is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions.

This laborious explanation is pointless. If someone feels depressed, they would by definition be distressed to some extent, and such distress obviously may interfere with ‘personal functions,’ whatever that means.

Obviously, if someone is unhappy for some reason, they won’t just be unhappy in isolation. If plied with leading questions, they may well admit to having additional symptoms, such as disturbed sleep, reduced appetite, loss of pleasure in previously enjoyable activities, and possibly even thoughts of suicide. Similarly, if someone seeks help for anxiety, they will likely have additional symptoms such as sweaty palms and an increased heart rate. But it is pointless to try to see if the ‘symptom score’ overall means the person can be placed in an arbitrary category, such as ‘major depressive disorder’ or ‘generalised anxiety disorder’, respectively.

This type of classification is a blind alley. It implies there are different kinds of ‘intervention’ which may be appropriate for perceived different degrees of these symptoms. Indeed, depression is now categorized as ‘less severe’ and ‘more severe,’ and the more severe the depression is deemed to be, the greater the emphasis is on drug treatment, of which there is a large number. But this classification has no demonstrable scientific or biological basis. If someone is judged to be more severely depressed, as opposed to a lesser degree, why should drug treatment be regarded as appropriate?

How can you know, then, if someone is feeling depressed? You can only know it if the person tells you so, although you may also judge it by their facial expression and general demeanour.

We should abandon the whole idea of treatment for depression. An unhappy person may be merely in need of reassurance, or be seeking a sympathetic ear and a shoulder to cry on. They should not be regarded as ill, that is, as if suffering from a ‘disorder’ and therefore possibly in need of a drug prescription. Sympathetic exploration of the background to the person’s distress is usually helpful, as well as consideration of their medical, family, and social history. Someone may also be feeling depressed for physical reasons such as an under-active thyroid gland or excessive alcohol intake. This is where the importance of assessment by a skilled doctor, especially a GP who knows the patient, cannot be over-emphasised.

But if the patient is regarded as suffering from a mental illness and referred to a psychiatrist, the implication is that the patient will be treated accordingly, that is, with drugs of one sort or another. It should be sufficient that the GP makes the initial assessment, and if he or she lacks the time or skill for to look further into the problem, then referral to a psychotherapist may be the best option. As for judging whether the patient is improving, you can only know this if the patient tells you so. Applying the crude approach of using a symptom score derived from a questionnaire will only tell you what the score is, which is not necessarily the same thing as a patient actually being improved. And if you’re trying to assess the effectiveness of drug treatment, this may be misleading. An unhappy person taking a drug may feel better because of a placebo effect, the passage of time, or because of emotional numbing induced by the so-called antidepressant. As for the standard advice to continue the medication for at least six months after starting to feel better, in order to prevent relapse, this is entirely arbitrary – but very good for the drug manufacturers.

Now let’s take a look at a document which has just come to my attention, published by NICE in 2022. We’re off on the wrong foot from the very title: ‘Depression in adults: treatment of a new episode of depression.’ It runs to 557 pages – no, this is not a misreading. What GP, or even psychiatrist, confronted with an unhappy person seeking help, will have waded through all this? And to think people get paid for writing such stuff!

What is an ‘episode’ of depression? Is depression something that comes out of the blue, as if it’s a disturbance arising spontaneously in the brain? (See my article on a case of depression reported uncritically in the British Medical Journal of a patient who felt not just a ‘click’, but a palpable (!) click, in his brain at the onset of his depression.)

Or could they mean, if the symptom of depression arises because of adverse life circumstances – bereavement, unemployment, bankruptcy, disappointment in love, etc. – that this causes a disturbance in the brain? In either event, calling it an ‘episode’ suggests it’s something that comes and goes, like migraine, which is an episodic headache in the intervals between which the patient is perfectly well.

Of course, someone may suffer unhappiness for a while, then recover, and some time later suffer from it again, but using the word ‘episode’ medicalises the situation, like talking of an episode of asthma or episodic runs of irregular heart beats.

It needs to be stressed that depression is a feeling or emotion – there is no evidence that it is a medical illness. This was recognised in antiquity: ‘Man that is born of a woman is of few days, and full of trouble.’ (Job 14:1)

Then we have the reminder that such treatment includes ‘pharmacological, psychological, psychosocial, and physical interventions.’ Is there anything they’ve left out? Furthermore, ‘different treatment modalities may be used in combination with each other, leading to a large number of possible permutations.’ Indeed, there could be thousands of them.

This biomechanical approach, as we might call it, to feelings of distress which anyone might experience as part of the normal ups and downs of life, now seems to be regarded by some members of the general public as a medical problem. People don’t just say they feel unhappy or distressed; they say they have something wrong with their mental health. This implies they may have a brain disorder, which is the ostensible reason for consulting a doctor, and this in turn carries the implication they may need medical treatment, that is, the prescription of a drug.

Perhaps what many unhappy people are seeking is a sympathetic ear or ‘a shoulder to cry on.’ The non-judgemental genuine interest of another person can be of great value in this situation. The approach is not to ‘get rid off’ the unhappiness, but to help the person find their own solutions to their problems, or at least to come to terms with them. In this situation, a therapist can help people become aware of the unconscious aspects of their problems, for example through dream analysis, and thus make real progress not only in resolving their difficulties but in achieving inner growth as well.

I should like to end by quoting from a paper in the British Journal of Psychiatry Bulletin by Professor Joanna Moncrieff (2018 Feb;42(1):42–44. doi: 10.1192/bjb.2017.11). The title is ‘Against the stream: Antidepressants are not antidepressants – an alternative approach to drug action and implications for the use of antidepressants.’

Here is the quotation:

It is possible that we misunderstand the nature of depression, and that regarding it as a discrete and universal disorder may have raised false hopes about the chance of a generally applicable ‘cure’ or treatment. The alternative view of depression as part of the spectrum of meaningful human responses to the world suggests that drugs will only dull the experience. In the end, the situation that provoked the negative emotion needs to be addressed. Depression is a signal that change is needed in some aspect of life. (My emphasis.)

Text © Gabriel Symonds

Picture credit: Etactics Inc on Unsplash