When the Blues Become a Clinical Ailment
One of the most important things we learned in medical school is how to ask the right questions to make a correct diagnosis. When a patient’s problem is straightforward, like a pain, the questions are typically quite specific. For example: “Where does it hurt?’ “Is the pain sharp or dull?” “Is it constant, or does it come and go?” “What relieves the pain?”
The answers patients give to these questions often provide clues that help us diagnose the problem. Sometimes, though, the most helpful questions are the more general ones. “What’s going on in your life?” “Are you happy?” “Is there anything bothering you that I should know about?”
There have been many times when questions like these--seemingly unrelated to a patient’s specific complaint--have triggered an outburst of tears and opened our eyes to the diagnosis of depression. There are several different kinds of depression; each can be accompanied by a wide range of emotional and physical symptoms.
The most serious form, commonly referred to as major depression, can cause people to experience profound sadness and to lose interest or pleasure in almost all activities. Most adults will occasionally feel sad or blue, but the sadness of a major depression is more severe and lasts longer (in fact, this diagnosis is made only if the symptoms last most of the day, every day for two weeks). People with major depression often experience other symptoms that do not typically occur with “normal” sadness. They may, for example, lose their appetite or have great difficulty falling asleep at night.
A milder but longer-lasting type of depression is called dysthymia. In this form of depression, the sadness is less severe but lasts years, and can be just as disruptive to a person’s life.
Depression can also be part of manic depressive illness (sometimes called bipolar disease)--a disorder characterized by periods of intense elation as well as periods of intense sadness. Depression is far more common than most people--including physicians--realize. In any given year, nearly one in 10 U.S. adults is affected by some type of depressive illness. About half of them--almost 9 million people over the age of 18--experience a major depression. Nearly 4 million adults suffer from dysthymia; millions more experience manic-depressive illness.
Unfortunately, depression often goes undiagnosed. Studies show that primary-care physicians fail to recognize this problem in approximately half the adult patients who actually have depression. Sometimes, depression is overlooked because the doctors failed to ask a “what’s going on in your life” type of question. Often, it happens because patients withhold sad feelings from doctors. They blame themselves for “being weak”; they fear being labeled as “mentally ill”; or they fear the cost of treatment.
Some people are kept away from the care they need by the depression itself, which robs them of their motivation to act. Failure to diagnose depression can be costly.
In addition to the emotional distress that depression produces, it is frequently associated with unpleasant physical symptoms such as headaches and digestive disturbances. Depression also diminishes a person’s ability to work productively (it is the leading cause of work-related disability in the United States). Most important, depression dramatically increases a person’s risk of suicide.
The good news is, once diagnosed, depression responds remarkably well to treatment: 80% to 90% of individuals with major depression, for example, will improve on the correct therapy. Treatment depends on the type and severity of the patient’s depression but typically includes prescription medications, psychotherapy or a combination of both.
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Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. They can be reached at ourhealth@dhs.co.la.ca.us. Their column appears the second and fourth Mondays of the month.
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Screening Yourself for Depression
Just as the doctor’s questions can help with thxe diagnosis, your own answers to a few questions can suggest if depression might be a problem for you.
* Do you feel sad or blue most of the day, nearly every day?
* Have you lost interest in things you used to enjoy?
* Have you lost or gained a significant amount of weight, or have you experienced a decrease or increase in your appetite?
* Are you having difficulty getting enough sleep or are you sleeping too much?
* Do you feel slowed down or restless?
* Do you feel tired or less energetic than usual?
* Do you question your self-worth or suffer from excessive or inappropriate guilt?
* Are you having difficulty thinking, concentrating or making decisions?
* Do you think about dying or killing yourself?
If you answer yes to five or more of these questions and your symptoms have lasted more than two weeks, consider talking to your doctor or a mental-health professional to discuss the results.
