How Do I know If I Or A Loved One Has Depression?

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“How would I know?” Since we started writing this series on depression, we have fielded various forms of this question from many of our readers.  This is not an uncommon question because diagnosing depression can be challenging, even for physicians. For example, the Agency for Healthcare Research and Quality found that while 25% of patients in primary care settings have clinical depression, only 31% of these patients are accurately diagnosed due to a combination of patient, provider, and system-related barriers.  Additional factors that make the diagnosis of depression difficult:

• Other medical conditions, such as thyroid disorders, anemia, diabetes, Parkinson’s Disease, and multiple sclerosis can mimic symptoms of depression.    
• People with depression may also have other psychiatric conditions like, anxiety, post-traumatic stress disorder (PTSD), and substance use disorders. 

Last month’s article was part one of a two-part article discussing how untreated depression, a prolonged fight-flight-or-freeze response, leads to premature aging and death.  This question posed by our readers actually aligns quite well with this month’s topic – the manifestations of untreated depression are both cognitive and physical. In other words, paying attention to how a person thinks, behaves, and feels physically, may indicate someone is depressed as long as you know what to look for. As a side note, most people who have depression do not self-refer for treatment, but are rather brought in by family, friends, or loved ones; it will be made clearer below as to why this is the case.  

In our 30 plus years of combined experience in psychiatry, here are some tell-tale signs that we look for when diagnosing clinical depression in adults:

Thinking symptoms, include:

• Illogical and irrational thoughts (i.e. “Everything in my life sucks,” “Nothing I do is good enough,” “Everything is my fault,” “There is no way out of this,” “I will always be alone and die alone.” )
• Repetitive themes of thinking that are OVERLY generalizing, pessimistic, hopelessness, black and white, and/or punitive-in-nature. 
• Difficulty with or inability to accurately self-assess – struggles with identifying and/or expressing one’s thoughts, feelings, or bodily sensations.  This is a major reason why people with depression don’t know that they are depressed and are often brought in for treatment by loved ones. 
• Difficulty making decisions / Indecisiveness
• Deterioration of cognitive abilities, such as focus and memory. 

Behavioral symptoms, include:

• Changes in sleep patterns – sleeping to much or too little
• Changes in eating patterns – Eating too much or too little
• Spending more time by themselves and decreased interactions with friends and family
• Less interest in or entirely dropping leisurely and pleasurable activities they once enjoyed

Physical symptoms, include:

• Chronic fatigue or low energy
• Weight gain or loss
• Frequent complaints of general aches and pains, severe headache, back pain/problems, digestive problems, stomachaches, and sexual dysfunction.

In addition to reviewing symptoms, screening tools are often utilized in diagnosing depression.  Here is a commonly used screening tool called the Patient Health Questionnaire – 9 (PHQ-9).¹

Patient Health Questionnaire-9 (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle the corresponding number next to the question to indicate your answer.)	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things	0	1	2	3
2. Feeling down, depressed, or hopeless	0	1	2	3
3. Trouble falling or staying asleep, or sleeping too much	0	1	2	3
4. Feeling tired or having little energy	0	1	2	3
5. Poor appetite or overeating	0	1	2	3
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down	0	1	2	3
7. Trouble concentrating on things, such as reading the newspaper or watching television	0	1	2	3
8. Moving or speaking so slowly that other people could have noticed?  Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual	0	1	2	3
9. Thoughts that you would be better off dead or of hurting yourself in some way	0	1	2	3
Add up each column for the Subtotals
Add up the subtotals for the  Total Score
Interpretation
Diagnosis	Total Score	Action
Minimal Depression	Less than or equal to 4	Suggests the person may not need depression treatment
Mild Depression	5-9	Consult a physician regarding whether the person should start treatment for depression
Moderate Depression	10-14
Severe Depression	15 or greater	Warrants treatment for depression

It’s time to drop the myths around depression.  Depression, far from being a heterogenous illness that varies from person to person, is a medical illness that is readily identifiable and treatable.   The problem lies in a clinician’s unfamiliarity with the illness and the varied ways in which patients may describe the symptoms. However, once correctly identified there are a wide range of effective treatments available.   Furthermore, there is a new and novel non-medication option called Transcranial Magnetic Stimulation (TMS) that is FDA-approved. But more importantly than the various types of treatment is the recognition that treatment is essential and, much like a bacterial infection, should NOT be ignored; the days of “let’s just wait to see if it gets better on its own,” or “just walk it off” or “buck up” are over.  As we have learned, there are profound physical and long term consequences should depression be left untreated. 

Reference:

PW Gold; “The organization of the stress system and its dysregulation in Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9 – Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613.