The problem here is that the article author (and us) are looking at depression from a very broad point of view including the social aspects of all forms of it, while the authors of the DSM criteria are looking at depression purely from a medical point of view. And medically, it is correct to include ALL forms of depression, including natural processes of grieving. They are medically indistinguishable by all measures currently in use. However, the author of this article is also correct - once we medicalise normal processes, we risk sidetracking these processes and sending messages that it is unhealthy to grieve, wrong to feel sad at times. On the flip side, we also risk devaluing the need for intervention in people who have serious clinical depression.
It is important to categorise the depression and to also allow a certain amount of it as understandable and appropriate in certain circumstances. The trouble is - where do you draw the dividing line?
I remember reading up on some research results, must have been 15 years ago now. The research was on brain waves and depression; they were trying to find some unique brain wave pattern distinctive in depression. They were fairly sure they had found it. They would hook patients up to the EEG and record brain waves, while interviewing the subject and asking them a series of questions (the same questions for all subjects). They had controls as well as people diagnosed with clinical depression. The interesting discovery (written up in the journal I was reading) came when one of the controls, who happened to be another researcher from the lab next door helping out for the sake of numbers, was still hooked up while they were taking a break from the process. He did not have depression and his brain waves indicated this. Then the researcher, in conversation, asked his control subject about his family. The control subject told him that his wife (or mother, or dog - I can't recall) had recently died, and while he talked about his very recent and raw grief, the brain waves changed drastically, and were indistinguishable to those found in patients with clinical depression. However, as he talked, the mood lifted after about fifteen minutes and the brain waves returned to normal.
The thing is - it was the sadness he felt while sharing his sad news, that produced the classic depression brainwave pattern. They went on to study this further and found this happens in everybody - when we feel sad about something, it resembles depression. The difference between this and clinical depression then becomes a matter of duration.
I remember attending a seminar on depression (about 1989) in which the distinction was made between clinical depression (aka endogenous depression - depression from within) and reactive depression, which I call depression for a known reason. We were told that someone with clinical depression is someone who cannot identify a cause; the emotion simply arrives like a raincloud. Reactive depression - you can generally define it as, "I feel sad because I lost my job," or some other stated reason.
But the presentation can be very similar. Also, if the emotion is preventing you from functioning, then you may need professional help in dealing with it.
I've experienced clinical depression as well as reactive depression. In my case, much of the clinical depression was actually caused by antidepressant medication which I had been put on to try to manage chronic pain. The depression would simply arrive, I would feel it sliding in and when I mentally went digging to find out why I felt sad, I couldn't identify a reason. I explored all possible options and my brain did not go "aha!" at any time. So I found the best way to handle this was distraction. Get busy, and distract myself until the bad feeling went away. But in someone who is too overwhelmed with this feeling, medication (or some other intervention) could well be needed.
Reactive depression - I could identify why. My mind would pounce on the cause and worry at it like a dog with a bone. "I'm depressed because I'm fed up with my chronic pain." Or "I'm depressed because it's raining when I had planned to go to the beach." I found I coped best with reactive depression, by actively focussing on why I was depressed, so I could begin to find a solution. Finding a solution eased the source of the depression which in turn eased my mood.Two different kinds of depression which initially feel the same, but had two totally opposite coping methods.
When I had the PSD, I was initially diagnosed with post-natal depression. But I wasn't depressed. I was angry. Furious. I felt I had been neglected, my pain ignored, my concerns dismissed. And it was fed and amplified by all the times in the past when the same sort of thing had happened. It became cumulative and so jumbled, that at first I couldn't identify the emotion or the reasons. It was beginning to feel like endogenous depression, except when I really felt for it mentally, I couldn't find the depression. I was crying a lot, but it was fear and anger. There was also a lot of grief in there too, jumbled with the anger. It needed professional help to find my way through the maze, doctors wanted to put me on medication. If I could tolerate the stuff it would have helped, even though my emotions were logical, natural, explainable and justified. But with professional help as well as some very useful help from friends as well as my own efforts, I began to find my way out of the maze. No medication.
So while I can see the concerns for the changes to the DSM criteria, it is working to include people who may be 'merely' grieving. It stops these people being disenfranchised. Because sometimes they need help too.
It will be a wonderful thing, when depression loses its stigma and gets the appropriate help. When that happens, we are less likely to medicalise what is normal and being managed.
When I was assessed by a psychiatrist specifically for depression (long before the PTSD) the summary was, "You have had some depression in the past, due to developing chronic disability and having to change career path. It was reactive depression and you dealt with it yourself. You do not currently have depression but it could return. If it does, call me. Until then, you don't need me."
I'm curious as to who the authors of the new DSM V are. I suspect I might know one of them. He's an Aussie researcher who specialises in depression (it was his talk I attended in 1989) and who has done a lot of work with CDC.
Marg
