Diagnosis of depression. Introduction

Depression is one of the most common psychiatric illnesses affects millions of people. Proper diagnosis and therapy of depression is crucial for individual’s recover. However, misdiagnosis is possible. Depression is difficult to diagnose as there are no precise laboratory or neuroimaging tests to confirm the diagnosis.

Depression is a debilitating illness reducing the social and professional performance of the affected individuals. In extrem cases depression can lead to full invalidism and often to suicide.

It’s important to understand that depression is a treatable illness and seeking help early improves the chances of full recovery. Without proper treatment, depression can worsen having destructive effect on the social and professional performance of the affected individuals. In extrem cases depression leads to full invalidism and often to suicide.

Symptoms of Depression

Symptoms of depression can be both psychological and physical in nature.

Psychological Symptoms of Depression

The main psychological symptoms of depression include:

Persistent, depressive mood
Loss of interest and joy
Lack of drive and fatigue

Additionally, there are several secondary symptoms that should be closely assessed as they contribute to determining the severity of the condition.

Secondary symptoms include:

Reduced concentration and attention
Diminished self-esteem and confidence
Feelings of guilt and worthlessness
Excessive worries about the future or a pessimistic outlook
Suicidal thoughts or attempts, self-harm
Sleep disturbances
Decreased appetite

Physical Symptoms of Depression

Physical complaints that may indicate depression are:

General physical weakness and fatigue
Sleep disturbances (difficulty falling asleep and/or staying asleep)
Appetite changes, gastric discomfort, weight loss, digestive issues like constipation or diarrhoea
Headaches or other bodily pains such as backaches
Sensation of pressure in the throat and chest (known as “globus sensation”)
Shortness of breath and disruptions in heart and circulatory function, like arrhythmias or palpitations
Dizziness, visual disturbances, and eye fluttering
Muscle tension and sudden sharp pains
Loss of sexual interest, absence of menstruation, impotence, sexual dysfunction

Diagnostic Criteria of Depression

Depression is diagnosed when there are at least two primary and two secondary symptoms present for a minimum of two weeks. Assessment takes into account not only patient’s current emotional state but also the course of the past few weeks.

Alongside typical emotional stressors, physical complaints can also indicate depression. Such symptoms like shortness of breath or heart rhythm disturbances might have psychological causes.

Severity Grades of Depression

Depression is categorized as mild, moderate, or severe based on the number of primary and secondary symptoms:

“Mild” depressive episodes involve two primary and two secondary symptoms lasting more than two weeks.
“Moderate” depression consists of two primary and three to four secondary symptoms.
A “severe” depression is characterized by three primary and four or more secondary symptoms.

Treatment options vary for each severity level. Hence, it’s crucial to identify all signs of the illness through thorough questioning.

Cultural Background and Depression

The cultural factors may influence symptoms of depression. For instance, in some cultural contexts, mental distress is primarily expressed through physical symptoms. This can sometimes make it challenging for doctors and psychologists to identify depression. Therefore, while diagnosing depression it’s essential to consider culture-specific factors and its nuances.

Distinguishing Depression from other Illnesses

The presence of depression symptoms doesn’t necessarily confirm depression. Many of these signs also align with other mental disorders. Fatigue or sleep disturbances, for instance, may occur in physical illnesses. Hence, the psychiatrist should, in the next step, inquire about other potential conditions and medical history to differentiate them. Physical examinations may also be included, offering insights into possible physical ailments as causes of depression.

Making Psychiatric Diagnosis of Depression

The diagnosis of depression is based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), mostly used in the US, or the International Classification of Diseases (ICD-10) deployed worldwide, among others in Europe.

Medical diagnosis of physical illnesses involves identifying the disorder or condition causing the symptoms. It relies on gathering information from patient’s medical history and physical examination.

In contrast, psychiatric diagnosis deals with psychological distress, which often lacks physical symptoms. Therefore, by making a psychiatric diagnosis, in this case of depression, mental health professional depends on patients’ descriptions of their thoughts and feelings, as well as their behaviour.

Psychiatric diagnoses serve two primary purposes: facilitating communication among healthcare providers and determining suitable treatment options.

Steps in Diagnosing Depression

Identifying depression is not always straightforward. Many individuals experiencing depression find it challenging to discuss their emotional state voluntarily. They often struggle to articulate their problems. One reason for this difficulty is that vague physical complaints can be linked to depression. Consequently, some affected individuals mistakenly attribute their symptoms to a physical illnesses.

Depression requires proper diagnosis which can be secured by a psychiatric assessment. Diagnosis of severe depression requiring treatment with medication typically involves few steps: a conversation with the psychiatrist, physical examination of the patient, Laboratory test, ECG and is some case CT or MRI scans.

The “2 Question Test”

An initial indication of depression can come from a simple test known as the “Two-Question Test”:

Have you frequently felt down, sad, or hopeless in the past month?
Did you have noticeably less interest and joy in activities you typically enjoy over the past month?

The answers “yes” to both questions may indicate depression. In that case, the psychiatrist will further assess the signs of depression by engaging in conversation and asking about specific symptoms.

Initial Conversation with the Patient (Anamnesis)

The most crucial tool for determining the diagnosis of depression and assessing its severity through conversation with the patient. The more openly and accurately the exploration, the better the assessment of the depressive state.

The conversation may begin with more structured interview containing a set of questions or in form of open-ended questions, such as why the person visits the doctor, how he feels, or what are the complaints.

The open approach allows the patient to incorporate better own thoughts and observations into the conversation. However, the patient may also want to discuss entirely different matters initially, such as recent experiences or challenging life situations. The therapist should approach the patient more flexible adjusting the interview to the circumstances.

During the conversation, the psychiatrist or psychologist pay attention to other details such as behaviour, clothing, or language. A soft-spoken tone, a lack of emotional expression, or a slouched and weary posture can provide clues about the individual’s condition.

Diagnosing depression, especially in individuals with severe physical or mental illnesses or in older adults, can be challenging. In such situations, it can be helpful to also interview family members or close caregivers.

Physical Exam

The objective of physical exam, laboratory test and other investigations, described below, is the exclusion of underlying physical illnesses, which can mimik depression.

Physical exam consists of:

General physical exam: assessment of patient’s general health status (depression may be linked to an underlying physical health problems).

Neurological exam: allows to roll out major problems of the central nervous system.

Laboratory tests

Evaluating the status of the patient before starting the treatment excluding different health issues. In case of starting treatment with medication the initial result is a benchmark for further controls.

ECG (Electrocardiogram)

By using ECG, we exclude pre-existent heart problems. A “native” ECG is also a point of reference for further controls under medication.

Additional diagnostics

A more profund investigation will be needed in case of severe mental disorders like psychosis or bipolar disorder. Such diagnostic includes brain scan (CT-scan or MRI) and the record of the brain generated electrical activity EEG (Electroencephalogram).

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Diagnosis of Depression