Many Diagnoses
of Depression May Be Misguided, Study Says
http://www.nytimes.com/2007/04/03/health/psychology/03depr.html?_r=1&oref=slogin
New York Times
April 3, 2007
By BENEDICT CAREY
About one in four people who
appear to be depressed are in fact struggling with the normal mental fallout
from a recent emotional blow, like a ruptured marriage, the loss of a job or the
collapse of an investment, a new study suggests. To avoid unnecessary diagnoses
and stigma, the standard definition of depression should be redrawn to
specifically exclude such cases, the authors argue.
The study, appearing today in The Archives of General Psychiatry, is based on
survey data from more than 8,000 Americans; it did not analyze the number of
people who had been misdiagnosed.
Psychiatrists and other doctors who take careful medical histories do so
precisely to rule out such life blows, as well as the effects of physical
illnesses, before making a diagnosis of depression.
But the American Psychiatric Association's diagnostic manual does not
specifically exclude people experiencing deep but normal feelings of sadness,
unless they are bereaved by the death of a loved one. And an increasing number
of school districts and health clinics use simple depression checklists, which
do not take context into account, the authors said.
"Larger and larger numbers of people are reporting symptoms on these checklists,
and there's no way to know whether we're finding normal sadness responses or
real depression," said Jerome C. Wakefield, a professor of social work at New
York University and the study's lead author.
His co-authors were Mark F. Schmitz of Temple University, Allan V. Horwitz of
Rutgers University, and Dr. Michael B. First, a psychiatrist at Columbia who
edited the current version of the psychiatric association's diagnostic manual.
The study's findings suggest that previous estimates of the number of Americans
who suffer depression at least once during their lives - more than 30 million -
are about 25 percent too high.
Dr. Darrel Regier, director of research for the American Psychiatric
Association, said, "I think the concern this study raises is real, and that we
do need to be very careful not to overdiagnose a normal, homeostatic response to
loss and call it a disorder." But he added that depression checklists had in
fact helped identify people in need of treatment.
The researchers analyzed responses from 8,098 adults to survey questions posed
between 1990 and 1992. The questions were based on diagnostic criteria for mood
problems and asked people who reported a period of sadness if they remembered
any event that might have caused it, like the death of a loved one or a divorce.
The diagnostic manual makes a distinction between severe bereavement that
precipitates lasting depression, which is rare, and normal grief, which looks
like depression but usually loosens its hold in a few weeks or months.
The researchers found 56 people in the survey who suffered this normal reaction
after the death of someone close. Another 174 people struggled with normal
levels of distress after a different kind of blow, like the breakup of a
relationship or a lost job - a group that would qualify for a diagnosis of
depression under the current definition.
The investigators then compared the two groups' answers to questions about nine
kinds of depression symptoms, including a loss of appetite, sleeping problems
and thoughts about suicide. The only significant difference, they found, was
that those grieving a death were twice as likely as those digesting another kind
of loss to have thoughts about death or suicide.
"The profile you get for these two groups is so very, very close," Dr. Wakefield
said, that it does not justify the exclusion of one group and not the other in
the depression diagnosis.
The authors draw no conclusions about the study's implications for treatment.
Doctors often treat even normal grief reactions if patients are in some pain.
But such patients should not be identified as having depression, the authors
conclude.
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