Types of Depression and Diagnosis
Distinguishing between sadness and depression is important. Sadness is a normal emotion that everyone experiences at different points in his or her life. We feel sad when we experience a loss or tragedy – and this feeling is usually an appropriate reaction to the situation that has occurred. Feeling sad is a natural coping skill that is required for growth and maturity. Experiencing sadness helps us to move through painful events.
When sadness manifests itself physically we may feel tension in our chest, or our hearts may ache. We may also experience an overwhelming desire to cry; and some are strongly compelled to talk with others about their sorrow. After expressing and letting out our emotions, we normally begin to feel a sense of relief. Unlike depression, sadness typically passes within a few days and one begins to embrace life again, enjoying normal daily activities.
In contrast to sadness, depression can seemingly come from “out of the blue,” and can last much longer. Someone may not even realize that he or she is depressed, and pinpointing any specific trigger for the depression can be difficult.
Different types of clinical depression have been identified. The first, which is commonly talked about, is “major depressive disorder” (also known as “major depression”). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), physicians will look for specific criteria when diagnosing a major depressive episode. These criteria dictate that five or more of the following symptoms must be present for at least a two-week period (these symptoms are generally reported by either the patient or a family member who observes the patient):
- A depressed mood for most of the day, nearly every day
- Loss of interest or pleasure in all, or almost all, activities for most of the day
- Significant change in weight or appetite
- Insomnia or excessive sleepiness
- Observable agitation or lethargy
- Fatigue and loss of energy, nearly every day
- Feelings of worthlessness, low self-esteem, or excessive guilt
- Difficulty concentrating or indecisiveness
- Recurrent thoughts of death or suicide
Additional symptoms may also be present, but these are not typically considered when making a diagnosis. Among others, these can include: a reduced interest in personal appearance and hygiene; complaints of aches and pains, with the worry of these symptoms being an indication of a serious health problem or disease; an increased sensitivity to noise; and bouts of crying or sobbing.
Another type of depression is known as “dysthymic disorder,” “dysthymia,” or “chronic depression.” Although this type of depression shares many symptoms with major depression, the symptoms tend to be less severe. These symptoms, however, are typically present for at least two years rather than two weeks (as with major depressive episodes). This form of depression sneaks up on patients, slowly becoming a part of everyday life, and eventually can be perceived as a person’s normal mood, often appearing unhappy. At least two of the following symptoms must be present to confirm a diagnosis of dysthymic disorder:
- Poor appetite or overeating
- Insomnia or excessive sleepiness
- Low energy or fatigue
- Poor concentration or indecisiveness; memory problems
- Low self-esteem
- Feelings of hopelessness
Bipolar disorder (previously known as manic-depressive illness) is a disorder which also falls under a separate category of depression. In this case, the patient will experience severe depressive episodes as well as periods of extreme euphoria. Additional categories of depression include postpartum depression and premenstrual dysphoria.
In general, the symptoms of depression can be divided into three categories: physical, emotional, and mental. The physical symptoms include fatigue, poor appetite, insomnia, and agitation. The emotional symptoms include feelings of hopelessness, depressed mood, low self-esteem, guilt, and worthlessness. The mental symptoms include poor concentration, indecisiveness, and for some, thoughts of death or suicide. The severity of depression can vary from mild to moderate to severe. Regardless of how severe one’s depression may be, it still affects us on all three levels: physically, emotionally, and mentally.
In all types of depression, symptoms typically impair daily functioning such as our ability to work or take care of household responsibilities. Doing simple tasks such as bathing or cooking a meal can seem overwhelming.
You may recognize several depressive symptoms that are also symptoms of MS. Examples of shared symptoms include fatigue, insomnia or excessive sleepiness, and cognitive difficulties, as well as restlessness or slowing down. Because many of these symptoms mimic typical MS symptoms, they may not necessarily indicate depression for someone with MS. The similarities in symptoms do in fact make diagnosing depression challenging in MS patients. A trained professional who is familiar with both MS and depression is needed to make an accurate diagnosis of depression for an individual with MS.
One of the most commonly used tools for diagnosing and evaluating depression is the Beck Depression Inventory (BDI, BDI-II), which is a questionnaire aimed at measuring the severity of one’s depression. The 21 multiple-choice questions allow adult patients to report on their depressive symptoms. Topics include: physical symptoms such as fatigue, loss of libido, and loss of weight; emotional symptoms, such as hopelessness and irritability; as well as mental (or cognitive) symptoms, reflecting any negative thoughts about the world, oneself, or the future.
The BDI is named after its creator, Dr. Aaron T. Beck, and was first developed in 1961. The questionnaire was revised in 1971 (BDI-1A), and has since been revised again in 1996 (BDI-II). All versions of this inventory for depression translate the degree of severity into specific numbers from one to three for each symptom. The self-reported ratings are added together to determine a total score, which gives physicians an exact number for the evaluation of a patient’s depression.
The Goldman Consensus Group (a panel of experts who reviewed the issue of depression in MS) recommends that individuals with MS be routinely screened for depression using a tool such as the BDI. They also recommend individualized treatment plans (using therapy, medications, or an integrated approach), greater standardizations of treating depression in MS, as well as continuing clinical research.