Shirah Vollmer MD

The Musings of Dr. Vollmer

Should Depression Be A Diagnosis?

Posted by Dr. Vollmer on December 2, 2013

Should depression be a diagnosi? The late Charles Brenner MD says no, and I agree.  Depression, like alcoholism, is a point of inquiry, a symptom of underlying dynamics which signal internal conflict and distress. Type I diabetes is a diagnosis. It suggests an underlying pathophysiology where the insulin production stops, yielding symptoms such as thirst and weight loss. The thirst directs the doctor to explore a known disease. Depression, like thirst, also directs the doctor to explore a disease, but unlike diabetes, we have not found that disease yet. Our ignorance, however, should not label depression a disease, when, in fact, it is a symptom. As a symptom, the doctor needs to remain curious about what underlies it.

Connor, fifty-two, complained that he was unhappy and did not understand why. He is married, neither happy nor unhappy with that, has a good job in finance, enjoys that, and has two college-age kids who do not live at home. He says he is at “loose ends.” What was striking about Connor was my sense of discord between his tone and how he appeared to me to be crestfallen. Tears came frequently to his eyes and he spoke slowly, with many pauses. The onset of his symptoms is always a curiosity, but Connor volunteered that he dates his problem to the fall, when his second child, his daughter, left for college. Until that time, Connor and Ashlynn were close and spent a lot of time together. Connor’s “unhappiness” on the one hand was a classic situation of loss, but on the other hand, indicated a time for inquiry into this new opportunity to find new and meaningful relationships. To say that Connor is “depressed” does not convey the transition he is going through as he sorts through his new emotional landscape. Yes, every mood is an opportunity for change, and as such, Connor is both held back by his mood, and propelled forward by the need to feel better. As with all symptoms, they are guideposts towards deeper understanding. A diagnosis is the end of that road. To have a diagnosis is to shut down curiosity and jump to treatment. This is both wrong and harmful. Connor might be helped by antidepressants, but he might also be helped by the understanding that loss triggered his “loose ends” and that his interior feels depleted, and so perhaps he needs to refuel.

6 Responses to “Should Depression Be A Diagnosis?”

  1. Ashana M said

    Symptoms occur as part of larger disease processes as well as for reasons we don’t understand. So it’s possible to have diabetic neuropathy, where it is part of a larger disease process, as well as ideopathic neuropathy, where we don’t know what the cause is. What depression is as a stand-alone diagnosis is ideopathic depression. That doesn’t mean it isn’t occurring as a part of a larger process, but it is quite possible for us not to know for a while–or ever–what that process is. And if there is no diagnostic category for symptoms we can’t find the cause of easily, some people will be unable to get treatment or have further investigation done. You cannot bill insurance repeatedly for something we can’t give a name to (or a billing code).

    But I actually think that most of what we see in the mental health arena are symptoms, which occur for a variety of reasons. Most symptoms are fairly non-specific. Both delusions and depression are sort of like fevers–general indications of being unwell. And I am actually of the opposite persuasion: I think we should stop trying to come up with specific categories of disease–because I am less and less convinced that most mental illnesses we have names for are specific categories of disease–and just start treating symptoms.

  2. Jon said

    I have a different, small, quibble with your statement, “A diagnosis is the end of that road.” Yes, the road goes from symptoms to diagnosis, but the road to me continues to treatment ideally ending in cure. Sometimes the treatment is to do nothing – a pathology may be self-curing; other times some form of intervention is necessary for a cure. Yes, a wrong diagnosis (or even a right diagnosis) can be seen a shutting down curiosity and jumping to treatment. However, a provisional diagnosis will keep curiosity alive. In this fashion both doctor and an engaged patient can look to the efficacy of the actions taken.

    So, in Connor’s case there seems to be at least two possible paths – the (perhaps too) simple path of antidepressant medication, and the deeper path of what causes his depression. Getting to the root cause of a problem and solving that seems preferable (and probably much harder) than treating the symptomatic depression.

    • Yes, Jon, I quite agree that a provisional diagnosis is the middle road between action and maintaining curiosity. If we could stay in the world of “provisional” that would be great, but it is my experience that once a diagnosis is laid out on a chart, however provisional the doctor might think it to be, this diagnosis becomes a limiting and reductionistic label which follows the patient in a way which constricts, rather than expands understanding. Thanks.

  3. Shelly said

    What do you mean by “refuel?” I know someone who continuously becomes depressed, withdraws into this depressive state for months at a time giving reasons such as, “Because this person or that became ill, I got depressed.” This person stays in the house, in bed, and waits for everyone to take care of her. This person does not make any attempt to understand the roots of the depressive episodes and gives external reasons for her depression. Why does she need to refuel so many times a year? Why does she inflict her depression on everyone around her?

    • Hi Shelly,
      By refueling I mean a process by which one feels that energy is coming in, rather than out. The person you are describing is organizing her mental existence around a more passive existence, and as such, she seems to think, at the moment, that there is little, other than withdrawing, that she can do to help herself. Her mindset appears stuck in that position. Thanks.

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