Depression is a term with several meanings that are easily conflated, and therefore leads easily to confusion. It can refer to a normal emotion, such as “I am depressed because I had to cancel my vacation to pay for a car repair.” It can refer to a symptom of another disease, which may be related to a separate physical or mental health issue. Or, it can refer to the DSM V definition of Major Depression, something that indicates a potential need for hospitalization.
There has never been an agreed-upon fool-proof way to differentiate depression as an ordinary emotional response to one’s circumstances, as a symptom of a different physical or mental illness, or depression as a disease in and of itself. However, there are guidelines to consider. A clinician must use common sense while also closely following the guide lines in accepted literature as to if, when, and how to use medications when a patient presents with depression.
As a psychiatrist, retired now for many years, I would like to say something about how one decides whether or not to prescribe a pharmacological agent. Unfortunately, although it should be obvious, it must be stated that anti-depressants should not be prescribed to a patient as soon as one hears the word depression. If the depression is Major Depression as described in DSM 5, medication is indicated. One has the impression that the patient can barely find their way to your office. At this stage, psychotherapy is likely to be experienced by the patient as you speaking in a foreign language. He/she simply is unreachable in any significant way through verbal communication.
Dysthymia, a long-term milder form of depression, is ill-defined. I might try using an anti-depressant but without genuine confidence that it would work for this classification of depression. I might try it on a short-term time-limited basis, but only as an adjunct to psycho-therapy, which is where I would expect to provide more benefit to the patient. Again, I am not averse to the use of anti-depressants, so long as it is used as an adjunct to psycho-therapy. One must be clear that Psychiatry is not an exact science.
The clinical features for Major Depression per the DSM-V have been well described in medical literature. Nevertheless, many psychiatrists fall into the sloppy habit of just prescribing drugs regardless of any refined analysis of a patient’s depression; forgetting what they have learned in preparation for their Board Examinations. Along with those psychiatrists, many doctors that are not therapists, and therapist that are not doctors, prescribe drugs based on the marketing propaganda of the pharmaceutical industry that exclusively promote anti-depressant treatment through chemistry.
In many ways, one must rely on one’s clinical experience. But, interpreting symptoms is always subjective. The nature of human beings is to isolate things within their environment in order to label what they perceive as a way to create order. Psychiatrists, and all therapists, are subject to that same innate perceptual process. One tends to “cherry pick” and organize perceptions that fit with one’s own pre-existing ideas, wishes, and habits. Without applying the most stringent self discipline, one will quickly embed a habitual view of patients who present with depression.
This has been a long-standing concern of mine. It is my clinical experience that the number of times a patient engages in self-harm does not necessarily reflect his/her depth of depression, or how important it is for them to be prescribed anti-depressants. There are other reasons than depression that prompt self-harm. I have seen many patients’ depression cease to be an issue once their reason to be depressed has been clarified and addressed. At the same time, this is not to say that pharmaceutical treatment is always wrong.
In my practice, I did use anti-depressants for some of my patients. Why? I believed their depression would be temporarily eased with some pharmacological agent such that they could proceed with psychotherapy. Nevertheless, in some cases, patients who arrived through referrals from other therapists with existing anti-depressant prescription, I tapered off and eliminated their anti-depressants in cases where I did not believe the drugs would help them. There are certain features of depression that may indeed respond to medications. However, seldom is it the case that psychotherapy is appropriately replaced by medication.
