It was really a touching moment for me. There I was muddling my way through the draft revision of the Diagnostic and Statistical Manual of the American Psychiatric Association (the document without whose authority psychiatrists daren’t give a patient a tissue to blow their nose), and I suddenly realised that the ever-thoughtful revision committee had come up with a diagnosis that could have been hand-crafted just for me:
300.4 – Chronic Depressive Disorder
A. Depressed Mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder
G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)
H. The symptoms cuase clinically significant distress or impairment in social, occupational, or other areas of functioning
Early Onset: if onset is before age 21 years
Late Onset: if onset is at age 21 years or older
Specify (for most recent 2 years of Dysthymic Disorder):
With Atypical Features
This is a direct quotation, by the way – I have no idea what happened to Criteria E and F. Also, the reference to ‘Dysthymic Disorder’ in the last Specify section is most likely a cut-&-paste error, since Chronic Depressive Disorder is a conflation of two diagnoses in DSM-IV: Dysthymic Disorder, and Major Depressive Disorder with a Chronic specifier.
So, yes, I am, to paraphrase what psychiatrists are always made to say in a bad Austrian accent in dodgy films, a ‘classic case’ of Early Onset Chronic Depressive Disorder. I wasn’t formally diagnosed with depression until I was in my mid-20s, but I first had treatment for the same suite of problems when I was 12 (under the old-fashioned, wise, system it was considered best not to pigeonhole kids with specific diagnoses), and I’d been experiencing them for years before then. Regarding Criterion C, frankly I would have been weeping with undisguised joy if I had experienced a break of two months in symptoms over the last two years (two weeks would have been cause for celebration), and it would be a rare day indeed in which I didn’t have 4 or 5 of the 6 symptoms specified in Criterion B. This is because I am, as regular sufferers readers of this blog know, pretty badly depressed a lot of the time. It’s not actually the depth of the depression that bothers me, though, (I’m used to it: I’ve learned how to deal with it: it’s pretty much ‘my’ version of normal), it’s the unrelenting nature of it, the way it just goes on and on and on, sometimes a little worse, sometimes a little less-worse, but never better.
On that level, this diagnosis is a step-up I think, since, for people like me, it may help to re-focus attention from the severity of depression to its chronicity. (Yes that is a real word, honest – it means ‘chronic-ness’.) In DSM-IV, ‘Chronic’ was only an additional specifier attached to Major Depressive Disorder, and it often didn’t seem that important to people involved in treating me. (In fact, I’ve only inferred from indirect comments that the ‘Chronic’ specifier has even been applied to me.) Their questions would always focus on the severity of the depression, and because I am reasonably high-functioning, and am rarely inclined to blab about what things really feel like to a doctor in a 10-minute consultation (I may be a poof, but I’m still a bloke, goddamn it), it’s always been presumed that I can’t actually be all that badly off. Very often concentrating on severity is absolutely the right thing to do, of course, because the majority of people with Major Depressive Disorder experience periods of low mood interspersed with longer periods of normal mood, and for them the defining feature of their illness is the severity of each depressive episode. That’s why I can actually see the sense of creating a separate diagnosis in which chronicity is the characteristic feature.
Of course, the other way of looking at the decision to integrate Dysthymic Disorder (a ‘mild’ condition for which most people wouldn’t have been prescribed medication) with chronic cases of the more serious Major Depressive Disorder (for which medication is usually prescribed) is that it’s probably increased the likelihood that people with a relatively benign symptom profile will be given drugs. This is perhaps significant, because one of the big worries around the revision of the DSM has been that it might be very heavily influenced by the pharmaceutical industry, and create a whole slew of new conditions, all of which can have pills prescribed for them. I think it’s entirely possible that the pharmaceutical companies will fairly rapidly ‘discover’ that a number of pre-existing medications – probably, by coincidence, the ones that are still under patent – are ‘effective’ against Chronic Depressive Disorder, and I think therefore also possible that some categories of patients who were previously med-free will be prescribed pills. Who knows, maybe some of them will even benefit from them.
Sorry, I can’t help but be a little snarky about the DSM, I’m afraid. But actually, my impression, having cast my wildly inexpert eye over (some of) the proposed revisions, is that there isn’t overwhelming evidence that the various committees have set about ensuring that there’s ‘an ill for every pill’. Quite a few of the revisions seem sensible to me, and some seem specifically aimed at reducing rather than encouraging over-diagnosis. For example, the proposal to do away with Asperger’s Syndrome as a separate diagnosis seems to have been influenced by the realisation that the criteria for the condition are rather vague, and that this had led to the diagnosis being used too ‘loosely’ (click on the ‘Rationale’ tab on the link for details). That said, there are plenty of cases where it seems as though the pharmaceutical companies will be pleased with what they find in the draft revisions.
For example, there’s the wholly new diagnosis, ‘Mixed Anxiety Depression’ (which, rather wonderfully, has the acronym MAD). What’s particularly worrying about it is that it’s proposed that the diagnosis can be made if symptoms have been present for as little as two weeks. It strikes me that a person worried about, say, an upcoming exam, or an operation, might well meet the criteria for being diagnosed MAD, even though, assessed over a longer period and particularly after the immediate stressor has been removed, they would seem to be perfectly healthy. Since MAD is inevitably going to be a medication-treatable condition – SSRIs and SNRIs are already marketed as being especially effective in treating patients who have co-morbid anxiety and depression – it strikes me it’s quite hard to see the ludicrously short qualifying period as anything other than an opportunity to create lots of lucrative new prescriptions.
Still, probably the most blatant example of pharmaceutical influence in the revision process is—
…something to be discussed tomorrow. Sorry, the post was getting ludicrously long, even by my standards, so I decided to sub-divide it. Plus I haven’t finished writing it all yet. Anyway, be sure not to miss the next thrilling instalment…