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When does depression become a mental disorder?

  • Mario Maj (a1)


How can we differentiate a depressive disorder from ‘normal’ sadness? This editorial summarises three approaches: the first emphasises the context in which depressive symptoms occur; the second postulates a qualitative difference between the two conditions; and the third argues that the distinction should be based on pragmatic grounds.

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1 Blazer, DG, Kessler, RC, McGonagle, KA, Swartz, MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry 1994; 151: 979–86.
2 Horwitz, AV, Wakefield, JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Oxford University Press, 2007.
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4 Helmchen, H, Linden, M. Subthreshold disorders in psychiatry: clinical reality, methodological artefact, and the double-threshold problem. Compr Psychiatry 2000; 41: 17.
5 Healy, D. Dysphoria. In Symptoms of Depression (ed Costello, CG): 2445. Wiley, 1993.
6 Clarke, DM, Kissane, DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry 2002; 36: 733–42.
7 Kessler, RC, Zhao, S, Blazer, DG, Swartz, M. Prevalence, correlates, and course of minor depression and major depression in the National Comorbidity Survey. J Affect Disord 1997; 45: 1930.
8 Kendler, KS, Gardner, CO Jr. Boundaries of major depression: an evaluation of DSM-IV criteria. Am J Psychiatry 1998; 155: 172–7.
9 Elkin, I, Shea, T, Watkins, JT, Imber, SD, Sotsky, SM, Collins, JF, et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments. Arch Gen Psychiatry 1989; 46: 971–82.
10 Broadhead, WE, Blazer, DG, George, LK, Tse, CK. Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA 1990; 264: 2524–8.
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When does depression become a mental disorder?

  • Mario Maj (a1)
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When should sadness be treated?

Neeti Sud, Core Trainee Psychiatry
02 November 2011

The article by Maj M is a useful addition to the literature. The author concludes that depression and sadness are not always qualitatively different. It is worth pointing out that the subjective perception of qualitative difference for the patients, carers or professionals would sometimes result in patient's presentation to the clinic. The author recommends pragmatic approach focussing on identifying thresholds one for condition deserving clinical attention and one for state requiring pharmacological treatment. He points out that the introduction of severitywith clear anchor points may help. Though this would definitely help define the problem but the treatment decision would still rely on the riskbenefit ratio. Moreover it does not replace either the context in which the patient presents nor the need to have a deeper understanding of the person, his developmental history and his personality.DSM 1V recognises the limitations of dimensional and categorical approaches of classifying mental disorders stating that although dimensional systems increase reliability and communicate more clinical information (because they report clinical attributes that might be sub threshold in a categorical system), numerical dimensional descriptions aremuch less familiar and vivid than the categorical names for mental disorders. Moreover, there is as yet no agreement on the choice of the optimal dimensions to be used for classification purposes. (DSM IV-TR pp, xxxi-xxxii)DSM IV defines mental disorder as a condition associated with harm involving a personal dysfunction, not merely an expected and culturally sanctioned response to a particular event such as major loss1. However problematic functioning may deviate from statistical norm of one referencegroup but not another group in relevant aspects (exposed to same life adversaries). Functioning may be an extreme or not so extreme shift from the average range whether temperamentally or acquired or both 2.

While we diagnose any disorder using purely descriptive criteria or involving abnormality in terms of either deviance from average group functioning or apparent breakdown of meaning either way the possibility remains that we might reliably diagnose non disorders as disorders2. The question whether they (mental disorders) are disorders or not should be shelved until we have done the requisite theoretical work on the notion ofdisorder and or aetiological models in science2. The DSM IV definition of Major Depressive Disorder includes the well knownqualifier 'symptoms are not well accounted for by bereavement that is after loss of a loved one'. The statement from Kenneth S Kendler on the proposal to eliminate the grief exclusion criteria from Major Depression states: 'There is little to no difference between individuals who develop depression in response to bereavement and other stressors. Majority of individuals develop depression in the setting of psychosocial adversity. Majority of individuals with terrible misfortunes do not develop major depression that does not mean that they do not feel terrible pain or loneliness. Diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means has the requirement that treatment is initiated 3.NICE (National Institute of Clinical Excellence, UK) recommends watchful waiting for mild depression. (Similarly NICE recommends watchful waiting for mild symptoms of PTSD if they are less than 4 weeks in duration from the traumatic incident). NICE recommends that when assessing a person who may have depression, clinician should conduct a comprehensive assessment that does not rely simply on a symptom count but takes into account both the degree of functional impairment and/or disability associated with the possible depression and the duration of the episode. It also recommends considering the risk benefit ratio before initiating treatment4.Spitzer and Wakefield state that the phrase 'clinically significant' acknowledges that there are many behavioural or psychological conditions that can be considered 'pathological' but the clinical manifestations of which are so mild that clinical attention is not needed5.After diagnostic evaluation if the criteria for major depression are met, it is appropriate to assess whether conservative 'wait and watch' approachis suitable or because of suicidal ideation, major role impairment or riskof substantial clinical worsening treatment benefits outweigh limitationsand our clinical experience and scientific evidence indicate that treatment is needed2.Because role norms vary considerably across cultures, ICD-10 avoids reference to role impairment in diagnostic criteria. Diagnosis and the need for treatment are not the same. Intense normal reactions to loss and stress can include distress, role impairment, and other deviations from homeostasis that can transiently resemble disorder. Access to professionalintervention in such cases is desirable, even if no disorder is present 6.The article discusses approaches to differentiate a depressive disorder from normal sadness. Induction of sad mood in non depressed volunteers hasbeen reported to alter activity in more than 70 brain regions with only modest agreement across studies. This has been speculated to be due to individual differences in capacity for emotional introspection. Also lack of objective measures of sadness may prevent detection of differences in what subjective states subjects label as sad. Many of the regions overlap with regions known to be hypoactive or hyperactive in imaging studies of major depression suggesting that sadness and depressed mood may have a common functional neuroanatomy7, 8, 9.

There are few models or studies of sadness perse but there are few distinct models identified in literature. In the 'detachment model' of sadness, sad emotion is believed to play a useful role in 'accepting' and thereby recovering from loss. An alternative model, 'reunion model' suggests that sadness is designed to promote reunion. Sadness motivates efforts at reunion (eg homesickness) but after irreversible loss is maladaptive7. In cases where reunion is not possible, by encouraging patient's sadness episodes to arise and unfold, without interruption over the course of bereavement or by using medication or cognitive reframing tosuppress them, the psychiatrist may inadvertently prolong the patient's grief by encouraging sadness, thereby developing complicated bereavement 7.The Caregiving model proposes that sadness strengthens attachment by inducing empathy in others. If sadness is protest behaviour it serves no purpose after permanent loss. If it is part of the despair phase of separation distress it has unclear evolutionary purpose. Some authors imply that it represents an adaptive mechanism7. Different models work fordifferent people due to personality constructs and context of life events.This argues in favour of the contextual approach, role of biopsychosocial model and multiaxial diagnosis. This also encourages us to explore the function of sadness.Gutheiel (1959) states that pessimism adds the element that changes sadness to depression10.When there is no adequate relational context in which sadness is experienced, expressed or validated, depressive reactionsdevelop10. Sadness changes to depression, as result of avoidance behaviourin relation to loss which blocks access to lost positive reinforcers11.People seek help because they perceive intense symptoms or recognise an undue prolongation and lack of progression in their personal response to stressor event. Though we are treating the neurobiology and the resulting symptoms, the cause is relevant as it is important to establish what patient thinks is making him/her sad in order for the treatment to be meaningful to the patient. As the diagnostic criteria would not be useful on their own to make that decision that is why threshold for clinical attention is lower than those needed for pharmacological treatment. The other option could be to make the diagnosis after treatment decision is made not before.There are implications of over and under diagnosis. Breast screening programmes may lead to detecting more malignant lumps12, at the same time there are serious physical and psychological implications of false positives. Strong emotions have a physical component and chronic high level of stress hormones may produce physiological and immune system changes and even lead to enduring structural change in vulnerable organ systems. Horwitz and Wakefield point out that 'women giving birth take painkillers even though pain is a normal part of the process but also notethat 'loss responses are part of our biological heritage'13.Higgins (Self discrepancy theory, 1987) states that different kinds of discrepancies between self state representations are related to different kinds of emotions, vulnerabilities and thus emotional responses. Sometimespeople who present many times, request treatment or those who attempt selfharm get diagnostic labels. A study on variance in detection of psychiatric illness found Doctor's characteristics such as 'interest and concern' or 'conservatism' to account for 2/3rd of the variance. The groupwith unrecognised depression were more tired and less likely to describe their depressed mood as qualitatively different from marked sadness. Otherstudies have found that concurrent physical illness is more prevalent in patients with unrecognised major depression and it is possible in these cases doctors are preoccupied with physical conditions to exclusion of depression14.Older people do not report sadness but present with other biological symptoms of depression. Subsyndromal disorders are also associated with significant functional impairment and disability15. Most studies demonstrate that patients with depressive symptoms even in the absence of a specific depressive disorder experience considerable morbidity and reduced social functioning15. The article summarises three approaches to differentiate depression from normal sadness, the first approach - the 'contextual approach' as used in the article and elsewhere16, is a misnomer as it postulates a qualitative difference (stating that depression contrary to normal sadness is unrelated to a life event or disproportionate to preceding event). The contextual approach would be what is summarised as 'Variation before loss - variation after loss'. How a person reacts to a stressor will depend on nature of event, place in relation to cascade of events, social and physical environmental contexts. How a person reacts will also depend on how the event and context interact with the person's personality structureand style of coping. Personality will affect the type of experience formed, the duration of each phase of response and whether or not adaptation is achieved. These personality differences can be individually formulated in clinical work and eventually might be included in a multiaxial diagnosis. Mental disorder cannot be diagnosed or treated without consideration of its meaning, possible resulting distress, disability and harm.

References 1 The Diagnostic and Statistical Manual of Mental Disorders (DSM IV), published by the American Psychiatric Association2 What is mental disorder: an essay in philosophy, science and values by Derek Bolton (International perspectives in philosophy and psychiatry), 20083 A Statement from Kenneth S. Kendler, M.D., on the proposal to eliminate the grief exclusion criterion from Major Depression ( NICE guidelines mild Depression: Spitzer, R. L., & Wakefield, J. C. (1999). DSM-IV diagnostic criteria for clinical significance: Does it help solve the false positive problem? American Journal of Psychiatry, 156, 1865-1864. 6 Does the DSM-IV Clinical Significance Criterion for Major Depression Reduce False Positives? Evidence From the National Co morbidity Survey Replication J. C. Wakefield, M. F Schmitz, and J. C. Baer, Am J Psychiatry, March 1, 2010; 167(3): 298 - 304.7 Peter J Freed,John Mann, Sadness and loss: Towards a neurobiopsychosocial model Am J Psychiatry Jan 2007; 164:18 Liotti M, Mayberg HS, Brannan SK, McGinnis S, Jerabek P, Fox PT: Differential limbic-cortical correlates of sadness and anxiety in healthy subjects: implications for affective disorders. Biol P 9 George MS, Ketter TA, Parekh PI, Horwitz B, Herscovitch P, Post RM: Brain activity during transient sadness and happiness in healthy women. AmJ Psychiatry 1995;152:341-351sychiatry 2000;48:30-42.10 From depression to sadness in women's psychotherapy, IP Stiver... - Work in Progress, 1988 - wcwonline.org11 Sadness, Depression and Avoidance behaviour, Alan M Leventhal, Behav Modif,2008, 32:75912 Parker G. Is depression over diagnosed? Yes, BMJ 2007;335:328,doi:10.1136/bmj.39268.475799.AD13 When sadness is a good thing TIME by CNN, John Cloud14 Why do general practitioners recognize major depression in one woman patient yet miss it in another? A T Tylee, P Freeling, S Kerry Br J Gen Pract. 1993 August; 43(373): 327-33015 Clinically significant Non major depression Old concepts, New insights Helen Lavetsky , Anand Kumar16 Maj M.Depression, bereavement and understandable sadness: should DSM 4 approach be revised. Am J Psychiatry. 2008 Nov;165(11):1373-5.

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Conflict of interest: None declared

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Why an objective depression diagnosis is so difficult?

Peng Huang, student
31 August 2011

Re: "When does depression become a mental disorder?" Maj, 199:85-86doi:10.1192/bjp.bp.110.089094

We appreciated Mario Maj's work. In this paper (1), three approaches were summarized by Dr. Maj to differentiate a depressive disorder from "normal" sadness. We obtained a more comprehensive understanding to depression compared to any time in the past.

Each approach has its advantage and endorsed by many people, but still not the final and convincing one. We obtain some viewpoints in the paper.

First, the depression has been a world issue not just in the USA and the high prevalence, in fact, the similar condition in China (2,3), is so crucial for the country, in particular, the psychiatrist and psychologist.Second, the depression diagnosis is not so easy, not only because the different diagnosis criteria (e.g. DSM-IV, ICD-10), but also the complicated life events, which perhaps the reasons for depression or "normal" sadness. Third, there's still not an objective diagnosis, which will eliminate all the misunderstanding and the debate.

So we have a question that why an objective depression diagnosis is so difficult? If we got one, just like a ruler that can measure the lengthof something accurately, do you think the DSM-5 or ICD-11 has the functionto diagnose depression more precisely? And do you think the physical change in brain (e.g. P300) is a marker to differentiate a depressive disorder from "normal" sadness, maybe we will find that the P300 is so different between the group of depressive disorder and the group of "normal" sadness, it's necessary to prepare an experiment using of ERPs orfMRI to test the thought.

1. Maj M, When does depression become a mental disorder? The British Journal of Psychiatry 2011; 199:85-86. 2. Lee S, Tsang A, Huang YQ, He YL, Liu ZR, Zhang MY, Shen YC, Kessler RC,The epidemiology of depression in metropolitan China. Psychological Medicine 2009; 39:735-47.3. Zhong B, Chen H, Zhang J, Xu H, Zhou C, Yang F, Song J, Tang J, Xu Y, Zhang S, Prevalence, correlates and recognition of depression among inpatients of general hospitals in Wuhan, China. General Hospital Psychiatry 2010; 32:268-275.

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Disorder versus Health

Andrew Shepherd, Doctor
11 August 2011

The discussion in this editorial by Maj can be related to a recent article in the British Medical Journal reviewing the definition of health.(1, 2) The authors proposed a definition of health on the basis of an individuals ability to react to perturbations in their physiological or psychological state - thus a healthy individual can respond appropriately to the challenge of viral infection, or life event. Failure of the appropriate coping strategy, whether purely physiological (e.g. inflammatory response), or psychological (e.g. defense mechanism) leads toillness. Social health is proposed to be the ability to respond to opportunities despite limitations imposed by ill health.

The conclusion of the BMJ article is a proposal that health could be measured through assessment of the biological, psychological and social domains through the use of appropriate measures for example the coop charts, or World Health Organisation methods. (3, 4)

A similar idea is contained within DSM-IV in the Global Assessment ofFunctioning Scale. Perhaps an adaptation of this could be used to provide a unifying measure of severity and definition of Mental Health Disorder. Diagnosis could be based on the presence of symptoms and their duration, the use of a uniform health rating scale for all disorders would allow forseverity grading. Treatment remains symptom directed, however the increased information provided by structured assessment would allow this to be focussed on specific psychological and social domains. Overall distinction between mental health and disorder would be determined by the impact of symptoms on global assessment of health.

(1) Maj M. When does depression become a Mental Health Disorder. BJP 2011 199: 85-86.

(2) Huber M, et al. How should we define health. BMJ 2011 343:d4163.

(3) Nelson E, Wasson J, Kirk J, et al. Assessment of function in routine clinical practice: Description of the coop chart method and preliminary findings. Journal of Chronic Diseases. 1987;40(Supplement 1):55S-63S.

(4) WHO. WHO family of international classifications;

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Depression: A Cultural Panic Attack

David P Geaney, Consultant Psychiatrist and Honorary Senior Clinical Lecturer
11 August 2011

Mario Maj overlooks the wider importance of an evolutionary perspective in discussing when depression becomes a mental disorder (1). He rejects the contextual approach, which considers whether depression is a normal response to circumstances, because of the difficulty of being certain that it was a proportionate response to specific adverse circumstances, with the consequent low reliability of the clinician's judgement. However, the contextual approach does at least have a significant degree of validity which is lacking in the current DSM-IV criteria, which are the equivalent of classifying any tachycardia, in excess of a particular rate or duration, as abnormal without considering whether it is occurring in the context of exercise or stress.

We recognise sadness or depression as the normal response to a range of major losses (including bereavement) and there is evidence that it occurs as a consequence of evolutionary design in view of the presence of equivalent responses in non-human primates, the response of human infants to the loss of a care-giver before socially acceptable responses are learnt, and cross-cultural universality (with a degree of cultural shaping). Specific mood states may give evolutionary advantages in particular situations that have been faced recurrently over evolutionary time. The possible benefits that depressive symptoms conferred, leading totheir natural selection over the course of human evolution, include protection from aggression after losses of status, attraction of social support, and promotion of disengagement from non-productive activities (2).

Depressive responses probably developed within small, egalitarian, cohesive, hunter-gatherer societies on the African plains whereas modern humans have moved away from the support of close relatives to function within many larger, less supportive groups, where they are subject to the mass media which encourages comparison to others of higher status, motivating the pursuit of unreachable goals (3). The depressive response mechanisms may be functioning normally in environments to which our brainshave not yet had sufficient time to adapt. The intensity of response to loss exists on a continuum within the population, related to the meaning of the loss for the individual and their underlying personality, and it isaccepted that the precise boundary between normal and abnormal responses is unclear. Yet, it is when depression is not proportionately related to real losses that it is truly disordered, and we risk excessively pathologising depression if we fail to consider context.

A tachycardia is the normal cardiac response to exercise and stress, and a cognitive misinterpretation of the tachycardia can lead to a panic attack. Sadness or depressed mood are the normal response to loss and our current cultural misinterpretation of the significance of these symptoms could be considered a cultural panic attack or health anxiety. There are consequences from this. Patients may be encouraged to consider themselves disordered and receive unnecessary treatment. Even if response to antidepressant medication is unrelated to preceding life events, this would not mean that a disorder was being treated. Psychiatric research into depression may be flawed because of the failure to distinguish normalfrom abnormal responses of the brain, and there may be a failure to adequately relate sadness to adverse social conditions, whilst promoting alack of resilience in society.

Allen Frances, the chair of DSM-IV, now believes the latter contributed to a false-positive epidemic of diagnoses of psychiatric disorder exacerbated by drug company marketing, and he argues that the current DSM-5 draft will worsen the false-positive epidemic because of lowering of the threshold for diagnosis (4). Disconcertingly, the current draft of DSM-5 ( from the Workgroup on Mood Disorders, of which Mario Maj is a member, proposes not to encourage the understanding of depressive symptoms in terms of the meaning to an individual of particular adverse circumstances, but instead proposes to remove even the bereavement exclusion from the diagnosis of Major Depressive Disorder, thereby removing context completely from diagnosis, exacerbating our current cultural misunderstanding and promoting the overmedicalisation of everyday life (5). Worrying times, exacerbated by the lack of an evolutionary perspective.

1.Maj M. When does depression become a mental disorder? Br J Psychiatry 2011; 199:85-62.Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Oxford University Press, 20073.James O. Affluenza. Vermillion, 20074.Frances A. The first draft of DSM-V. BMJ 2010; 340:c11685.Wakefield JC. Misdiagnosing normality: Psychiatry's failure to address the problem of false-positive diagnoses of mental disorder in a changing professional environment. J Mental Health 2010; 19:337-51

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