12 March 2004

Depression often misdiagnosed and incorrectly treated

Depression is often not recognised or taken seriously. It is also not always treated correctly, says Prof Michael Simpson.

“My GP said it is only a mild depression, so I only need a small dose of a mild antidepressant.”

I often hear this sort of comment, and it makes me shudder, as it represents a very serious problem which prevents many people from getting proper treatment for their depression. Let's run through the many problems included in such a statement.

First, there's a common misunderstanding of the nature of depression itself, and the person in this situation may not be significantly depressed at all. Depression is one of the commonest human afflictions. It is serious, it hurts and it has a significant death rate (mainly from suicide); a death rate rather higher than that of many other diseases which are treated more seriously by everyone.

In some ways, it's unfortunate that the disorder has come to have such a simple name: "depression", rather than an impressive technical term - or it might get more respect. Depression is a word, like anxiety, which is in common use for a wide range of states, including depression, but also many milder, more transient situations - such as the blues, feeling down in the dumps, sad, disgruntled, disappointed, displeased, unhappy, cheerless, gloomy, downcast and so on.

Major depression
The presence of so many terms, in most languages, for such negative moods, shows how common they are. But the sort of serious depression that needs serious treatment, goes beyond these (while often including all of them) and involves a range of biochemical changes in one's brain function. Indeed, some specialists talk of a "biochemical depression" in order to make the distinction. All these other, lesser, mood states deserve respect and concern, but they are significantly different in degree and in significance.

What makes a major depression a significant illness rather than these unpleasant but briefer and more shallow moods, is the depth, extent and duration of the change in mood, and the extent of its effects on normal functioning. Depression certainly features a severe degree of depressed mood, though some people seriously affected by it experience the other symptoms more severely and may not even recognise their state as depression. The criteria which specialists and doctors use to diagnose depression look for this miserable mood to be present for most of the day, nearly every day. All normal people have variations in their mood, and it dips down for some of the time. But that isn't depression.

Closely related to this is another criterion we look for, and one that is often even more reliable in indicating the presence of a real depression: a markedly diminished interest in whatever usually interests you, a loss of pleasure in what usually pleases you (technically called anhedonia ).

The state should represent a real change from someone's previous state and not arising from an obvious immediate cause such as the death of a loved one (though depression can arise in the course of a bereavement); and it causes functional impairment: you are significantly less able to function as well as you usually do.

There are several other features common in depression, which people often do not recognise as related, such as fatigue and loss of energy, difficulty in concentrating and making decisions, and feelings of being unworthy, and guilty, far in excess of anything that might be a reasonable response to events. In a number of areas of functioning, the symptoms may swing in either direction - one may have insomnia, or sleep excessively, still not feeling refreshed by it. There can be increase in appetite and weight gain, or loss of appetite and weight loss; and one may become agitated and restless, or retarded and slowed down. Commonly, also, there are recurrent thoughts of death and futility, and thoughts of suicide.

This, then, is Depression with a Capital D, and the situation in which antidepressant drugs can be very useful, indeed life-saving. While Depression can vary in severity, unless it is severe enough to meet the set of criteria specialists use to make the diagnosis, it is not severe enough to benefit from antidepressant therapy at all. Too often, when the doctor says you have a "mild depression" he is hedging his bets. He is not really convinced whether the problem is severe enough to need serious and proper treatment. Far too often, he then talks of giving a minor or mild dose of an antidepressant drug.

Drugs must be used properly
Now comes the second problem. One must either use the antidepressant drugs properly and in a sufficient dose to have a significant impact on correcting the biochemical abnormalities than have arisen in the depression; or not use it at all. For each such drug, there is a minimum dose below which it will not produce any benefits. Lower doses may well give nasty side effects and even some risks, without any risk of benefiting the patient. It is simply an expensive and unpleasant way of taking needless risks. Many research studies and surveys have found that a great many patients in general practice are receiving far too little of the drug to be able to benefit from it. Some of the people who say they have been treated with antidepressants, but without feeling better, fall into this category.

Doctors also often fail to wait long enough to see if a drug is working. Effective antidepressants may help to improve some aspects of your depression even earlier, but generally need a good two weeks to make a substantial difference to your condition. Too often, as a specialist, I see someone referred to me who has been given almost every antidepressant drug known to medical science, but who has had none of them in a sufficient dose or for a sufficient period. They might in fact respond excellently to any of those drugs, but have usually so thoroughly lost faith and confidence in that possibility, as to make their treatment needlessly difficult.

I also, too often, see patients whose depression has been treated with drugs which have no useful antidepressant effect, like the Valium family of tranquillisers. Such chemicals can even worsen a depression and increase one's impulsivity, which can be dangerous - just as alcohol, self-administered by many people in an effort to find a way to feel better, can have the same unfortunate effects.

Some drugs, especially the older antidepressants, have more side-effects, and one may very well start on a rather low dose, and gradually increase it to the effective level. This is fine, so long as the process is supervised by a doctor who knows what she is doing, and so long as the effective blood levels of the drug are reached. Newer antidepressants have less noticeable side effects, and can even be started at a potentially effective dose from the start. One may need to tolerate some degree of side effects, and accept them as a sign that the drug is getting to the right places and also doing what you want it to be doing.

A medication that is totally free of side effects would probably be just as free of effects and benefits, as well. Even a placebo a dummy medication, consisting of starch, sugar pills or an injection of sterile water) usually also has side effects. In drug trials using a placebo in comparison with an active drug, some patients complain bitterly of the side effects of the placebo, even stopping the non-existent drug, calling it intolerable.

Depression often not noticed
Some doctors, who were never very well trained in psychiatry when in medical school (the medical schools in South Africa rather ignored this important aspect of medicine until the last decade or so) don't take depression seriously enough. They may not recognise it when they see it. Depression often acts as an amplifier of any other symptoms one has, making them feel worse and harder to tolerate. Thus, depressed patients often go to see their doctor with other complaints at the top of their list (and doctors are often in such a hurry that they never let you tell them more than the top one or two complaints on your list).

We find a very high incidence of treatable and curable depression among patients at general medical or surgical outpatients departments or in medical or surgical hospital wards. Depression which amplifies pain may worsen someone's complaints about a relatively unimportant problem and lead to them being wheeled in for surgery, which will not solve their major problem.

Depression can be sneaky, either coming on so gradually that you don't really notice how severely it is affecting you before you are fully in its grip; or developing relatively rapidly, so that the tiredness, indecisiveness and hopelessness it causes within you, lead you to be inactive, give up and not take action to see a suitable professional who can help you get better.

Depression influences way of thinking
The effect depression has on your way of thinking can be profound and dangerous. It fosters feelings of helplessness and hopelessness, as well as a feeling that you are only being a nuisance and really don't deserve to be helped. All these feelings are false and inaccurate - but dreadfully sincere, convincing, and seductive.

Research has shown the extent to which a depressed person, without realising it, selectively ignores the good news of the day and discounts anything hopeful, while selectively focusing on everything that is potentially bad news, gloomy and discouraging. It's a perfect recipe for getting and staying more depressed. This is why, as well as drug treatment which is so effective in so many people, some specific types of psychotherapy such as so-called Cognitive-Behavioural therapies, can also be most useful.


The effect of these changes in one's way of perceiving the world and in evaluating one's situation, is to increase the danger of suicide. It is important to say that neither one's own thoughts of suicide, nor anyone else's "threats" or discussions of the subject, should ever be lightly ignored or discarded - all need to be carefully considered and the degree of risk assessed.

That's the other, often terribly final, reason why I feel a chill when hearing about someone's depression being lightly dismissed or treated with tiny doses of perhaps the wrong drug. Far, far too many people have died because of such failures. There are frightening statistics from several research studies showing how many people saw their own doctor in the month before killing themselves, often within their last week of life. There, surely, there could have been a real chance to recognise the situation and to deal with it effectively.

General practitioners and other doctors, as well as mental health workers, have a major responsibility to consider the possibility of the presence of a significant degree of depression and of suicide risk when they see and assess patients, whatever the person is "officially" complaining about. If they find a good reason to diagnose depression, they must see that the person gets an effective dose of an effective treatment.

These drugs are not like salt, something you can simply sprinkle over someone, to an individual taste. Either they are used effectively, or there is no point in using them at all. In fact, the ineffective and feeble doses so popular among some GP's probably increase the danger. Because they cannot work effectively, they may add the burden of pointless side effects and convince the person that, as the treatment is not working, their situation may be hopeless, when this is not so.

The responsibility should also be shared by patients, friends and families. If you are the depressed person, you have a responsibility to yourself and to those who care about you, so make sure that you see someone suitably trained, and that you reveal all aspects of how you feel, including thoughts of suicide where these are present. Friends and family should also encourage this. Being depressed is usually no more your fault than is having appendicitis, so be frank and play as active a part as you can in your own recovery.

In a very real and important sense, there is no such thing as that "mild depression". If it's really mild, it isn't depressing.

- Prof Michael Simpson

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