The Truth About Depression: Choices for Healing
By Charles L. Whitfield, M.D.
Medawar asked, "If DSM-IV were a fishing net... what mesh size should be used to catch depressed fish but not others?" He answers, "The mesh has been getting smaller over the years, but is this a good or bad thing?" Since its first edition in 1952, the DSM has contributed to helping legitimize a dramatic increase in drug use among so-called "mental health" patients. To diagnose what it calls "major depression," in addition to having a sad or down mood (criterion Al), the DSM-IV requires the finding of only four of its remaining eight symptoms or signs, from decreased appetite to low energy to low self-esteem.
A More Likely Cause
Does such a diagnosis of "depression" automatically indicate that people will require the daily ingesting of antidepressant drugs (ADPs) to heal from their condition? Does it mean that they have only one kind of depression-i.e., the "genetically transmitted" variety, and therefore should automatically be prescribed ADPs? When might other treatment aids be indicated? When we find a person with symptoms of depression, how should we proceed with making a differential diagnosis? Several observers have emphasized that "depression" is not a single disorder, but that it has a number of subtypes. These include the two major ones of exogenous (external) and endogenous (internal) origins, with further subtypes under each of these. I and others believe that treatment of the whole person would be based on the origin of the depressive symptoms, and not on the assumption of a proposed genetically based disorder alone.
For the person with bothersome endogenous (internally generated) depression, i.e., a person whose history and other findings have no exogenous (external) causes, perhaps a trial on an ADP would offer this person a chance of lessening their symptoms for a time. In my estimation, at the most, endogenous depression appears to make up no more than 30 to 40 percent of all depression. However, for the person with exogenous depression, treatment would include measures that would be appropriate for ameliorating the particular cause(s) or associations.
"Anxiety" (which I usually prefer to call fear) is a common part of depression, and "depressed" people often have other comorbid disorders, including anxiety disorders such as post-traumatic stress disorder (PTSD) (common among trauma survivors), personality disorders, thought disorders (schizophrenia or other psychoses) and addictions. Each of these has a specific treatment approach-and ADPs may or may not be an appropriate part of the regimen. Some clinicians believe that a brain serotonin abnormality has more to do with anxiety than with depression, but since 1990 drug companies have promoted it for depression more than they have for anxiety disorders, so by habit we tend to associate it more with "depression."
Not only does depression occur commonly as a part of PTSD, but PTSD can mimic nearly every diagnostic criterion of depression.
What this can mean for any given person is that they may not have a simple biological disorder that clinicians can call "depression." They may also have another, perhaps more important one: PTSD. And PTSD suggests some kind of trauma, for which there is now a way to heal from its numerous and varied effects. Thus, making a preliminary diagnosis of depression only opens a door for us. It does not let us see the contents of the room, much less enter into it so that we can explore it further. So it is up to us as patients and clinicians to keep our awareness at a maximum so we can find the real cause of the depressive symptoms and signs. A problem is that people with symptoms of depression may feel so down and have such a low energy that they don't have the full awareness to look for the real cause without outside help.