Low Mood or Depression? Language or Label?

I, like many others witnessed the storm between Mind Charity and India Knight yesterday, largely with sadness.  I respect Mind an enormous amount and believe that they have done more than most to help people with mental health difficulties and raise awareness of the same issues.  I don’t know India Knight at all and haven’t really read her work, but I did read the article.

I don’t like a fight so am staying away from who’s right or wrong, in fact I’m going to offer a different perspective and it’s on the point which I think cause most of the outcry.

“everyone gets depressed….” 

This was responded to with fury.  I can see why but I also see her point.  Most of the anger was in the form of “depression is a mental illness, you can’t just get over it or it’s not the same as low mood” So is this right? What is the difference between low mood and depression? It’s not a straightforward answer by any means.

Just to be clear of my perspective, I don’t think that it’s necessarily an illness. (Please read on) I do think and believe very strongly that it is a disabling problem which can devastate lives.  It has had a massive impact on my family and many others but I do not think that people with ‘depression’ (I’m using quote marks for reasons to become clear) are totally different people to those without.  If that was the case there’d be a clear line between them and I don’t think that’s true.  I do think that some people experience a range of symptoms of such intensity and over a period of time that it can take over their lives.

I come from the perspective that I could, at some point in the future have ‘depression’ there is no doubt about that in my mind.  I don’t at present, but that doesn’t mean I won’t have it in the future.  I also don’t think that I will wake up tomorrow with it, I don’t think that it can come on overnight (in someone who the day before was not experiencing difficulties or who had not had a seriously negative incident that day).

So what is ‘depression’?  And how is it different to low mood?  The way Mental Health services are set up and run in this country, the dominant model of services is a medical perspective.  I know and I welcome gladly the increase in psychological therapies (there is more to helping someone that therapy though, but that’s a whole different post) but even they are increasingly assigned using diagnosis.

Most mental health diagnosis is based on a polythetic model (ie if can have 4 out of the 7 listed symptoms etc then you meet diagnostic criteria).  In the UK either the ICD-10 or DSM-IV are used, both considered the ‘bibles’ on diagnosis.  You can read them and decide who has what.  They also differ, which presents it’s own challenge to the model.  I’m going to use the DSM–IV criteria to illustrate my point (I will get there eventually), but I could use ICD-10 equally.

To illustrate this please consider Alan, Alan presents with:

(1)    depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
(4) insomnia or hypersomnia nearly every day

These difficulties have troubled Alan for 2 weeks and they are having a major impact on his ability to undergo day to day tasks.

What do you think? Does he sound depressed?

He does NOT meet criteria for a Major Depressive Episode.  Would you say he has depression?  What about if he was like this for 2 years?  Is that depression?  Using this system the answer is still no.

Now Brian presents with these difficulties:

(1)    depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
(4) insomnia or hypersomnia nearly every day

So far he’s exactly the same as Alan.

BUT, he also experiences:  a loss of energy every day.

Brian has also had these symptoms for 2 weeks and they are having a major impact on his ability to undergo day to day tasks.

He DOES meet criteria for a Major Depressive Episode, what many would call ‘Depression’.

(He has 5 of the listed symptoms, Alan only has 4)

This is plain wrong.  To say that Brian has an illness or a disorder and Alan does not makes no sense whichever way you look at it.  Not everyone experiences fatigue, people’s experiences of depression are different, because a) people are different and b) depression can present in different ways (for example many young men display anger but are more often afraid or depressed).

Using the categorical system, Brian has ‘Depression’ and Alan does not.

Brian has an illness, Alan does not.  I cannot subscribe to that way of thinking at all.

In one of my many arguments about this issue with people who do subscribe to the medical model of mental health they will occasionally say” well as an experienced clinician I wouldn’t deny Alan has depression just because he has one symptom less” But then where is your cut off?  And why use a yes/no model anyway if you’ll make your own mind up regardless?  There is no cut off, that’s the reality.

Some say we need diagnosis to inform prognosis, nope.  Alan may well do just as poorly as Brian.

Some say we need diagnosis to inform treatment, nope. Would you refuse Alan for CBT? Or medication? Of course not (I hope!!).

Can we not use the word depressed, as in ‘I was depressed today’? Without people being offended?  I don’t think it’s the same as saying ‘I had depression today’.  But this use of the language and labels is not helping anyone, people use them interchangeably.  People can have depressed mood and not enjoy something they normally do and feel tired, for a day or a bit longer but many others really struggle with low mood and lots of other difficulties such as fatigue, hopelessness, diminished pleasure for a long time.  We need to consider the person first then the problem.

Many people say “I was really anxious about that”, not many people would react angrily to that but some people and I have worked with many, are completely and utterly disabled by their anxiety, often to the extent that they see taking their own life as they only way out.  Is what they experience qualitatively different to the fear others can experience?  No, not always.  Is it quantitatively different, yes.  It is the degree to which it stops THAT person living THEIR life which is the issue.   I have worked with people with obsessions and compulsions (an anxiety based difficulty) who hold down successful jobs and others with very similar thoughts and behaviours who cannot get out of the house for hours at a time as they get so stuck.  The difference is in the severity of the difficulty, not necessarily what the difficulty is.

That is why I pursue (at times overly so – I admit) a psychological model of mental well-being, I don’t think using a categorical system reflects human experience, nor does it help society to understand the nature of psychological well-being and distress.   I and most Clinical Psychologists subscribe to a continuum model of mental health on which we all lie.  What is important is the degree to which that problem is impacting on the individual, not whether they have 5 rather than 4 symptoms.

More and more stigma is a hot topic.  But saying that people with mental health issues are categorically different to people without is a) not evidenced base (buzz phrase!) or b) helpful to society as a whole.  Understanding mental health is not about those that have it Vs those that don’t, we’re all in it together, we all have a role and responsibility.  We have to be able to discuss these issues with respect, on twitter, at meetings, with politicians, with each other.

It’s not them and us, it’s us.

We all need a language to talk about mental health, but labels help no-one.

GJM

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