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What Depression is Not


When one is feeling low, it doesn’t necessarily mean that one is going through the throes of clinical depression, i.e., major depressive disorder. There are several conditions that may mimic clinical depression but don’t reach the severity or pervasiveness of the former condition or are symptomatically distinct. It is important to recognize these so that one may not unnecessarily get prescribed medications or started on psychotherapy as some of these conditions are time limited or may remit on their own. At the same time, some of these conditions such as complicated grief may need specialized therapy. Conditions that resemble depression but are not depression include the following:

Sadness: Depression is more than the normal pangs of sadness one gets when experiencing a stressful situation. Depression is a more pervasive and persistent change in your mood along with changes in your physiological functions such as sleep, appetite, and energy level. Although stress can trigger a depressive episode, not everyone faced with stress becomes depressed. And, sometimes depression can occur without any specific triggers and may not respond to changes in environment (the so-called endogenous depression), which differentiates it from sadness. Moreover, while sadness can disrupt your day-to-day functioning, the effect of depression is more significant, though some researchers believe that this criterion is not clinically meaningful to distinguish sadness from depression (Wakefield et al., 2010). In contrast to sadness, depression is associated with a pattern of negative or distorted thinking which perpetuates the symptoms (Burns, 1999).

Bereavement: Bereavement and depression have a complex relationship. The Diagnostic and Statistical Manual of Mental Disorders – fourth edition, text revision (DSM-IV TR) excluded depressive symptoms occurring up to a couple of months after a loss as being a sign of a major depressive episode (American Psychiatric Association, 2000). However, depression arising after a loss of a loved one is no different compared to that arising due to a job loss or recent divorce or “out of the blue” (Pies, 2014). Moreover, not diagnosing depression during grief can potentially divest such people from getting timely help; professionals may defer treatment until symptoms persist or become more severe. In tandem with these observations, the DSM-5 doesn’t consider bereavement as an exclusion for diagnosing depression.
Certain symptoms may help one distinguish when bereavement may have transformed into depression (American Psychiatric Association, 2013). These include persistently sad mood that doesn’t improve with changes in environment, lack of pleasure, feelings of worthlessness, pessimistic or self-critical ruminations, and suicidal thoughts related to negative feelings about self.

Complicated grief: Another condition called complicated grief or as the DSM-5 calls it, the “persistent complex bereavement disorder,” also mimics depression. In short, this is characterized by preoccupation with the deceased or the circumstances related to death, feelings of disbelief or numbness, excessive avoidance of reminders of the loss, a desire to die in order to be with the deceased, social withdrawal, and persistence of other intense and impairing symptoms of acute grief beyond the socially and culturally accepted norms (American Psychiatric Association, 2013; Shear, 2015). Complicated grief differs from depression as it an extension of the normal grieving process and usually lasts more than a year while depression is a clinically diagnosable entity. Approximately, 7% of grieving individuals develop complicated grief. Women and those with preexisting mental illness, substance use, trauma history, limited social support, and multiple recent losses are more at risk of complicated grief (Simon, 2013). Screening tools such as the Inventory of Complicated Grief can help people with prolonged grief arrive at a proper diagnosis (Prigerson et al., 1995). Although, antidepressants have been used to treat complicated grief, it is best treated with focused psychotherapy.

Adjustment disorder with depressed mood: Stressors – breakups, job loss, marital conflict, natural disasters, or life changes such as school, illness, marriage, divorce, retirement, etc. – can cause a heightened emotional or behavioral reaction in some people. If you experience low mood, tearfulness or feelings of hopelessness within three months of a stressful situation and these symptoms subside after the stressor is over, the diagnosis is more likely to be adjustment disorder with depressed mood (American Psychiatric Association, 2013). Compared to depression, adjustment disorder always has a clear precipitating event, is time limited, and never meets the full criteria for depression. Psychotherapy is the mainstay of treatment for adjustment disorder with depressed mood.

Premenstrual syndrome and premenstrual dysphoric disorder: Premenstrual symptoms, starting a week before the onset of menstrual cycle, range from mild physical or behavioral symptoms in premenstrual syndrome to marked mood changes – irritability, crying spells, depression, and anxiety – in premenstrual dysphoric disorder. The latter is also characterized by changes in sleep, appetite, lack of interest, difficulty concentrating, increased sensitivity to rejection, and physical symptoms such as feeling of “bloating,” breast tenderness or swelling, or joint/muscle pain. The symptoms in premenstrual dysphoric disorder are severe enough to interfere with normal functioning. However, unlike depression, the symptoms subside after the onset of menses and don’t represent an amplification of pre-existing depressive symptoms (American Psychiatric Association, 2013).

Adapted from the evidence-based book The Complete Guide to Self-Management of Depression: Practical and Proven Methods.  To find out if you have clinical depression, check this blog post.


HARPREET S. DUGGAL, MD, FAPA

REFERENCES

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Association.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Burns, D. D. (1999). Feeling good: The new mood therapy. New York, NY: Avon Books.
Pies, R. W. (2014). The bereavement exclusion and DSM-5: an update and commentary. Innovations in Clinical Neuroscience, 11(7-8), 19-22.

Prigerson, H. G., Maciejewski, P. K., Reynolds III, C. F., Bierhals, A. J., Newsom, J. T., Fasiczka, A., Frank, E., Doman, J., & Miller, M. (1995). Inventory of complicated grief: a scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65-79.

Shear, M. K. (2015). Clinical practice. Complicated grief. The New England Journal of Medicine, 372(2), 153-160.

Simon, N. M. (2013). Treating complicated grief. The Journal of American Medical Association, 310(4), 416-423.

Wakefield, J. C., Baer, J. C., & Schmitz, M. F. (2010). Differential diagnosis of depressive illness versus intense normal sadness: how significant is the “clinical significance criterion’ for major depression? Expert Review of Neurotherapeutics, 10(7), 1015-1018.


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