Depression Often Goes Untreated: When to Seek Professional Attention

We all know individuals who are of a more melancholy disposition than others. In A. A. Milne’s popular set of children’s stories, the friends of Winnie-the-Pooh include both Tigger – the bouncing, happy tiger; and Eeyore – the somber, plodding donkey. Even from a young age, we all understand that it is completely acceptable for individuals to have their own unique dispositions and levels of emotional valence.
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However, when a friend or loved one’s general tendency towards being blue seems to worsen, and perhaps begins to impair day-to-day functioning, it is exceptionally difficult to assess the seriousness and potential danger of the situation. In particular, it can be hard to know when a period of melancholy crosses the line into untreated major depression.

Depression Can Be Misdiagnosed

A recent study published in the JAMA Internal Medicine journal by the American Medical Association indicated that in the United States, a large proportion of individuals seeking attention for depression-related symptoms are misdiagnosed. The study surveyed over 46,000 US adults aged 18 or older in 2012-2013.

Using an established scale to measure depressive symptoms, the study established that around 8.4% of the participants in the sample had depression. However, only 28.7% of those individuals had received treatment. Meanwhile, of those who were undergoing treatment for depression (either psychotherapy or antidepressant medication), only 29.9% screened positive for symptoms of major depression.

This means that there are some serious challenges associated with the correct identification of depression, and diagnosis and treatment is not necessarily always straightforward.

In an effort to widen the scope of research into the prevalence of depression misdiagnosis, another study conducted a meta-analysis of 118 different studies assessing the accuracy of depression diagnoses. The final analysis contained data from more than 50,000 patients across 41 different studies, in countries including the United States, Canada, and various European countries, among others.

In the end, the study suggested that for every 100 cases of potential depression seen by a primary care physician, 15 cases are false positives (treatment was prescribed when there was no real depression), 10 cases are missed (treatment is not prescribed when there is real depression), and 10 cases are correctly identified (treatment is provided for real, identified depression).

One reason for this pattern of diagnosis is the difficulty in ascertaining the difference between depression and psychological distress. The AMA study described in the previous section measured the difference between depression and serious psychological distress, and found that among adults who were undergoing treatment for major depression, 29.9% had depression and 21.8% had serious psychological distress.
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In addition, factors such as age, culture, and available medical resources can impact diagnoses. In general, the studies concluded that developing a relationship with a mental health care professional and undergoing multiple diagnostic visits over a longer period of time can substantially increase diagnostic accuracy.

Signs to Look For

To address the complexity of depression diagnosis, there are several mnemonics that have been developed in an effort to make the symptoms of depression more memorable. The mnemonic below, published by Blenkiron, 2006, lists 10 symptoms of depression aligning with the 10 letters of the word. Here we present the list and supplement each item with a brief description.

• D = Depressed mood

Depressed mood is a feeling of sadness or negative affect that sustains throughout the day. It is generally worse in the mornings.

• E = Energy loss/fatigue

In major depression, the feeling of low energy or physical fatigue will occur almost every day. It’s also important to note that real, inexplicable physical symptoms such as back pain or headaches are commonly reported.

• P = Pleasure lost

Also called anhedonia, this loss of pleasure refers to a marked decrease in the level of interest or pleasure one takes in daily activities which repeats for a sustained period of multiple days.

• R = Retardation or excitation

The word “retardation” here refers to a slowing down of thinking, speaking, or movement. Alternatively, with major depression there can be a feeling of mania. This can include angry outbursts, anxiety or restlessness, or general agitation.

• E = Eating changed—appetite/weight

Changes in eating can fall along opposite extremes in major depression: In many cases, individuals report decreases in appetite and weight loss, but food cravings and weight gain are also reported.

• S = Sleep changed

Similarly, changes in sleep can fall on opposite sides of the spectrum. Both insomnia (lack of sleep) and hypersomnia (sleeping too much) are commonly reported, occurring over a period of multiple days.

• S = Suicidal thoughts

This symptom of suicidal ideation – often the most alarming for friends and loved ones – can also be the most misunderstood. To be an indicator of major depression, thoughts about death or suicide must recur for a period of multiple days, not simply a single off-the-cuff remark or a joke made in poor taste.

• I = I'm a failure (loss of confidence)

When feelings of failure or fixations on past failures increase in frequency for a period of multiple days, this becomes a possible indicator of major depression.

• O = Only me to blame (guilt)

Underlying the persistent feelings of guilt that are symptomatic of major depression is a general feeling of worthlessness. Individuals with major depression may assign themselves blame for something that is not their responsibility at all. This must occur nearly every day for multiple days to indicate depression.

• N = No concentration

Individuals often report an indecisiveness and a lack of mental clarity that keeps them from attending to and remembering the events occurring around them. When this lack of concentration repeats over a period of multiple days it can indicate the potential for major depression

As was apparent from the list above, each symptom presented must recur in an individual for a period of multiple days before it should be considered a possible indicator for major depression. Generally speaking, until multiple of the symptoms above are present much of the time for a sustained period lasting around two weeks, there should not be major cause for concern.
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However, anyone with any concern over the mental health or safety of a friend or loved one should consult with a mental health professional. Individuals who fear for anyone’s immediate safety should contact emergency services.

By Dr. Syras Derksen,
Registered Psychologist
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References

Blenkiron, P. (2006). A mnemonic for depression. BMJ: British Medical Journal, 332(7540), 551.
Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of depression in primary care: a meta-analysis. The Lancet, 374(9690), 609-619.
Olfson, M., Blanco, C., & Marcus, S. C. (2016). Treatment of Adult Depression in the United States. JAMA Internal Medicine, 176(10), 1482.