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August 23, 1999 | Why is the concept of depression so elusive?

As a practicing neurologist, I see plenty of depression masquerading as physical complaints, the patients either unable or unwilling to acknowledge that the mind can create all kinds of physical symptoms (constant headaches, neck and low back pain, non-specific dizziness, and so on). These are patients who best benefit from treatment of depression. The problem is in getting them to recognize it.

I see a second group of people -- the chronically disgruntled, with the lifelong hangdog expression -- who insist they are depressed when the problem is probably not depression. Rather, they have a variety of personality disorders ranging from standard passive-aggressive behavior ("What can you do for me?") to a constitutionally based inability to experience joy.

Whoa. What right do I have to say what others are feeling? That's the very attitude that has put doctors on the top of everyone's least-loved list. But this is the question: How does anyone know if someone else is depressed?

Is the person's word good enough? Take a look at late-night TV. Is the teenage girl who laughingly says of her boyfriend, "he makes me so depressed," talking about the same thing as someone who can't get out of bed and who seriously considers suicide? Is this merely a matter of degree, or are we talking about different emotions, different underlying neurochemistry?

Isn't there something more rigorous about the diagnosis of depression than subjective reporting?

The National Library of Medicine Health Services defines clinical depression as "a mood disorder as opposed to a normal reaction to life's difficulties. Not only is the mood affected, but there are often cognitive, behavioral, and [physical] symptoms." So far, so good. But here comes the problem. "The mood disturbance may include apathy, anxiety, or irritability in addition to or instead of sadness."

May include? Maybe? Using this standard psychiatric definition of depression, one could argue that irritability may be the sole manifestation of depression. But irritability can simply be self-indulgent behavior without any emotional implication. Certainly there is a difference between petulance and grief.

Contrast hopelessness, discouragement, despondency with bitterness, resentment, frustration, disappointment. They do not feel the same. Why not say "I am suffering from frustration," rather than using depression as a blanket all-inclusive diagnosis?

If we are to understand depression, each of us needs to be the self-analytical equivalent of a novelist. We need to understand nuances of feelings, shadings, subtle distinctions in mood. We need to be self-aware and able to describe our feelings with some precision. We would not think of lumping all forms of growths together. You don't need chemotherapy to treat a wart, though a wart is as much a growth as any cancer. And you don't need Zoloft to treat resentment.

Next page | Depression is like pornography -- I know it when I see it