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7. Diagnosis of depressive illness

Depressive illness cannot be diagnosed by a blood test or a scan – there is no single test that can diagnose depression with certainty. What the doctor is looking for is evidence that a person is ill, and ill with depression – they are not able to function normally and they feel different. They feel that they have changed, and are ‘not themselves’. The doctor will ask questions about your symptoms. The person who is depressed will experience many of the changes described.

Question: What’s the point of seeing a doctor about my moods anyway? Surely they’re my own business?

Answer: We all have differing moods, they are our own business, and they’re all part of what we like to call life’s rich tapestry. The world would be a very bland place if everyone was in the same mood all the time. Moods are our natural reaction to what happens in our lives. Sadness follows a loss, anxiety follows a threat, and these moods help us deal with life; but sometimes a bad mood is prolonged and does not naturally return to a comfortable level. Persistent disturbances of mood can cause poor functioning and loss of ability. When your moods interfere with your enjoyment of life, illness might be developing. Depressive illness is a curious condition. Unlike most other illnesses, quite often someone who has become persistently low and sad is the last to recognise that they have changed. Sometimes there is a very obvious reason why someone is upset; sometimes our moods change without obvious causes, perhaps for quite deep-seated reasons. Physical illness can trigger off depression, so can certain drugs (official and otherwise). Even the climate can perhaps affect some people. When your level of functioning is affected – for longer than a couple of weeks – it’s sensible to consider seeking help.

Question: My wife’s had lots of tests in hospital for suspected stomach ulcers. Nothing has shown up but she still feels awful and has lost weight. The doctors are saying its depression. How could this make her feel so ill?

Answer: Maybe a third of people who are investigated for common symptoms such as stomach disorders, or chest pain have no abnormality that can be found. All the tests, such as endoscopy (looking inside the stomach with a video camera), blood tests and barium X-ray come out normal. We know that a depressive illness can underlie these symptoms. Perhaps the best analogy is of the molehill being turned into a mountain by depression, which subtly affects the many ways we perceive how our own bodies are working. Most people get some sort of indigestion at times, but, if you are run down and depressed, the fairly minor aches and pains from this can be magnified. If you have some worries, or feel that it just might be cancer, you are less likely to be reassured by normal test results. Having these tests done can in itself be quite stressful and make you more anxious. In this situation it is often helpful to let some time pass, and to keep in touch for review. Then we can look at any new symptoms and reconsider the question of depression once they have had a chance to digest what we’ve said. It is important for doctor and patient to keep an open mind.

Question: What does the term ‘dual-diagnosis’ mean?

Answer: Dual-diagnosis is a term that is used when someone has a combination of a psychiatric illness plus a problem with alcohol or substance abuse. Some people may be more vulnerable to substance abuse because of their depression or other psychiatric conditions; others may be trying to control their own feelings by ‘medicating’ themselves with alcohol or street drugs. Perhaps a third of substance abusers have an underlying psychiatric condition. This may be masked by their drug or alcohol use, and presents a double challenge to medical care. Until both conditions are recognized as being present, it will be hard to make much progress. Expert psychiatric assessment is generally needed to unravel this sort of situation. Unrecognized, the second problem will interfere with treatment of the first one.

Question: Where can I get help?

Answer: Start with your family doctor. A physical check-up and some blood tests may be helpful to exclude any medical condition that could be making you run down. Talking always helps, so try to confide in a friend or family member. The hotline in many countries, local clergy, school or work counselors can also help you to take the first step. Don’t put up with it, do something about it. Part of being depressed is feeling that nothing can or will help. That’s untrue. Depressive illness is eminently treatable.

Question: Why is a brain scan recommended for some depressed people?

Answer: Brain scans are of two main types: CAT (computed axial tomography) and MRI (magnetic resonance imaging). The MRI scan tends to give a much more detailed picture of the anatomy of your brain. Very rarely the development of a resistant, or atypical depressive illness, is associated with the presence of a brain lesion (an area of damage of some sort). Sometimes, a small stroke is the unrecognized cause or, very rarely indeed, a brain tumor (most often benign). Brain scans can pick up, or more usually exclude, such lesions. The first onset of depression in late life may be associated with dementia (such as Alzheimer’s disease), and a brain scan may be able to demonstrate some atrophy (brain wasting) in these circumstances. Other types of brain scan (PET, SPECT) are at present of research interest, but not of clinical usefulness, in depression.

Question: My family doctor has referred me to a psychiatrist. Does that mean I’m going mad?

Answer: No. It does mean that you are going to have a longer and more detailed assessment and a specialist opinion on the best treatment for you. Most – perhaps 90% – cases of depression are managed well by family doctors. The more complicated cases, for example where there hasn’t been a good response to treatment, are referred for a consultant opinion, and this can also give you access to more treatment resources, such as hospital-based therapies.

Anyone can get this illness: we are all potentially at risk. People of all ages, from every culture and every socioeconomic group can become ill with depression. What differs in different ages and cultures may be the way that the illness shows itself.

Depressive illness in a teenager may look very different from depressive illness in an old person. The depressed teenager may be very tired, lacking in energy and irritable. The depressed older person may be restless, tense and sleepless. Depressive illness in, for example, rural India may show itself with extreme concern and distress about physical complaints rather than tearfulness and low mood, which may be the dominant features seen in a depressed European. The illness, whoever it affects and whenever it strikes, is equally disabling but differently expressed.

In this course we speak about some specific groups of people who may become depressed, and the different ways in which they may be affected, including children, adolescents, women who have recently had babies or have reached the menopause (and discuss whether men may experience anything similar), older people, people addicted to alcohol and drugs, people with seasonal affective disorder (SAD) or chronic fatigue syndrome. We also talk about how bereavement, shock and injury or violence can trigger off a depressive illness.

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