Is my patient really depressed?...

Many patients report sadness or distress during consultations with primary care health workers. Such emotions may be related to grief and other life stresses, including the stress of physical illness. Sometimes sadness appears out of the blue, without obvious relation to external causes. Over recent decades there has been an increasing tendency, especially in primary care, to diagnose depression (commonly major depressive disorder) in patients presenting with sadness or distress and offer them antidepressant medication.

The rates of diagnosis of depression have risen year on year to the extent that in the USA 11% of the population aged 11 and over now take an antidepressant, including 23% of women in their 40s and 50s. In England, antidepressant prescribing has increased at over 10% per year between 1998 and 2010 - mainly explained by an increase in longer-term prescriptions. Apart from their pharmacological action, the placebo effect of antidepressants is statistically significant. Some of the prescribing comes from healthcare practitioners feeling a strong need to do something, to fix a problem and to feel effective in healing sadness. The challenge is, instead, for the doctor to be able to remain present with the patient in their loss or sadness, to be there in the process of grief until the patient can come to a new place of security and peace. The sheer volume of sadness, or perceived sadness, is these days immense, and practitioners can find it difficult to commit to the time necessary for the counselling this may take.

The area most commonly misdiagnosed is when a loss has occurred, whether that be a death, a divorce, abuse, job loss and so on. The feeling of injustice, failure and grief is more than folk can sometimes bare without support. Calling these natural but painful experiences depression is a medical intrusion into private emotions. Cross-cultural factors may make this worse, and people from other cultures can experience deep shame if they are labelled depressed; they may feel weak, disempowered and judged.

So, before diagnosing depression, listen carefully to the patient’s story and consider the context:

* Has the patient experienced grief or other life problems?

* Are symptoms mild and recent?

* Is this a first episode?

Mild symptoms, or symptoms related to grief or other life problems, usually do not become more severe over time and an immediate diagnosis of depression should be avoided whenever possible.

Patients with mild depressive symptoms may not need antidepressants - as any benefit is likely to be due to the high placebo effect. Mild symptoms, or symptoms related to grief or life events, are often likely to resolve with time, and psychological support.

What is needed is more training for nurses, doctors and healthcare practitioners on how to handle sadness, loss, grief and the feelings of anger that can accompany injustice.

How do you as a health professional offer help to someone who is sad, or possibly depressed?

Can you offer them a listening discerning ear, emotional and spiritual advice? And hope?

Ros Simpson

Further reading:

Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit.

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f7140 (Published 09 December 2013)Cite this as: BMJ 2013;347:f7140  Christopher Dowrick, professor of primary medical care, Allen Frances, emeritus professor of psychiatry