The term “clinical depression” is commonly used these days to indicate a more serious depressive state. It is a phrase that is not well defined and that may be used with various meanings. It is therefore important to understand what this term may mean and what are the possible ramifications of its common use.
The word “clinical” comes from the Greek meaning “of the bed”, and is defined in most dictionaries to refer to the assessment and treatment of patients. Clinical depression should therefore refer to any depressive state that requires medical treatment. Wikipedia equates “Clinical Depression” with Major Depression, which is just one of the DSM mood disorders that could require treatment. The situation is further confused by the common practice in the media and psychopharmacological literature to drop the word “clinical”, and just refer to “depression” as if it is a singular entity.
The term has been around for a long time, even prior to the development of the DSM system of mental disorder classification. The former diagnostic model classified depressions primarily as either neurotic or endogenous. Neurotic depressions were presumed to derive from unconscious conflicts, while endogenous depressions were thought to be of biological origin. The term “clinical depression” was equated, in those days, with endogenous depressions, and thus had an association with the concept of a biologically based depressive disorder. One of the main reasons for the development of the DSM system was the impossibility to actually deduce etiology from symptoms in most psychiatric disorders. DSM diagnoses do not imply etiology, but are simply recognized symptom clusters. Major Depressive Disorder does not imply a biological root of the diagnosis. The term “clinical depression” is most often used to imply a Major Depression, but the association that this implies a biological etiology has remained in many peoples’ minds. What is Major Depressive Disorder? It is the depressive diagnosis that has been most commonly studied. Every psychiatrist is well acquainted with the severe forms of depression that one sees in hospitalized patients. Research has repeatedly shown that this type of depression, that used to be called Melancholic Depression, responds best to anti-depressant medication. It is from these severe depressions that the idea of a biological etiology was first derived. The diagnosis of Major Depression includes a much broader range of patients. The DSM is best used as a guideline, and not as a recipe book, to help one put measurable symptoms to complex clinical situations. Clinicians who work with hospital psychiatric populations know the feeling of the unreachable depressed patients whose demeanor shows no response to any interpersonal interaction. This sense of the patient being trapped in a dark fog is almost always present in the most severe Major Depression. The DSM criteria do not in themselves indicate this aspect, and are open to wide interpretation. Major Depressions are sub-classified by severity as mild, moderate or severe. While identified as a single diagnosis, the etiology, treatment and prognoses of these varied severities may be very different. What can be even more confusing is that a severe depressed mood does not necessarily indicate that a person has a Major Depression. Extremely depressed moods may occur in Adjustment Disorders, and commonly occur in Axis ll diagnoses. This means that a person who meets the criteria for a Major Depression may on any occasion appear less depressed than a person with another condition. In the real world, individuals may be diagnosed as having a Major Depression simply on the intensity of their mood. The suggestion that one has a “clinical depression” may thus be applied to varied diagnoses, fitting the term’s linguistic meaning, but not its intended use. The ramification of this is serious. It means that individuals that have depressive diagnoses with even far less evidence of a primary biological etiology than Major Depression may be told that they need medication based on assumptions about the term “clinical depression”.
A crucial aspect of the DSM diagnosis of Major Depressive Disorder is the persistence of the symptoms. Symptoms need to be strongly present, every day or almost every day. There has to be significant and serious loss of pleasure in most aspects of life. One problem in assessing depressed moods is that when an individual is feeling depressed at the moment, that individual’s perception of how severe symptoms have been over the past while will be distorted by the depressed mood. Frequently, people will report being depressed all the time, but on close questioning it may become apparent that they have inconsistent symptoms. Certain symptoms, such as insomnia, fatigue, loss of energy, or trouble concentrating or making decisions are not specific to depression, but are common in any stress related disorder. In order to consider these as relevant symptoms of depression, they should be present in a clearly different manner than the individual has experienced at other times of stress. Equally important, the symptoms should all hold together as a distinctive picture. The diagnosis should not be made by trying to fit the individual into the various symptoms, but by the symptoms clearly indicating a cohesive syndrome. Far too often, practitioners will make the diagnosis by fishing for symptoms, such as finding a depressed mood, and then saying: “the patient does have some sleep disturbance, and some fatigue, and really isn’t functioning or enjoying life as well as usual”. Almost anyone who is feeling depressed could be fit into the diagnosis of Major Depression if the practitioner tries hard enough. This is not how the diagnosis was intended to be used.
The use of screening questionnaires or on-line tests further complicates the issue. These types of tests are often poorly validated. While constructed to pick up Major Depressions, they don’t tend to differentiate between Major Depression and other mood disorders. They can have a high degree of false positive results. The tendency of these tests being used to promote the concept of “chemical imbalance” is problematic. The pharmaceutical industry has been highly involved in the development and financing of some of these tools. The lack of adequate mental health resources in our society frequently results in screenings and questionnaires being used as a short cut to a prescription, rather than as an entry to a proper diagnostic assessment.
It appears that the term “clinical depression” is used as if it’s synonymous with Major Depression, often assumed to imply etiology like Endogenous Depression, but may be applied to anyone who is experiencing a serious depressed mood. Should the term continue to be used? It is useful to assert that anyone with a serious depressed mood or consistent feelings of unhappiness deserve to be taken seriously. The use of the term to denote a biological etiology is clearly inappropriate. The idea that “clinical depression” is a singular entity has to be considered to be erroneous. Proper information about clinical depressions, and educational programs for practitioners and the public would be important to encourage proper understanding, diagnosing and treatment.
Norman Hoffman, M.D., FRCPC