Re: Major Depressive Disorder (MDD)

This morning I posted the following on my tumblr1 account (link to original post):

MDD is associated with a mortality rate of 15% — suicide.

50% of people with MDD receive no treatment.

What other disease has a 15% mortality rate, yet we do so little to get them help?

It was subsequently reblogged by myvonne with her “rant” (her words). Here is the link to her full response, unadulterated by my annotations.

Now, I don’t know myvonne at all. It appears she reblogged me through another reblog. So she may or may not ever read this response. But if she does, I want her to know this:

  1. I understand that your own personal life experiences have shaped whatever strong views you hold that must have fueled that rant.
  2. If we, the medical profession, have wronged you or your loved ones, I am sorry. That probably means nothing coming from a stranger over the Internet who hasn’t even graduated medical school yet, but still… I’m sorry. The profession isn’t perfect. We have made mistakes. And too many of us are socially awkward enough that we might not always communicate very effectively. I have strong opinions about they way doctors communicate with their patients. Quite frankly, I think that we have done a poor job.
  3. Please don’t take this response personally. I don’t mean to attack you in any way. My response is to the words you wrote. If we were sitting across from each other, talking face-to-face in a patient-doctor conversation, I probably wouldn’t disagree with you at all — at least not for a while. Because I’d sit there and ask questions about what makes you feel the way you do. But the context is different here. And again, I don’t even know if you will ever read this.

With that being said, I felt compelled to respond to a few things I read in the reblog of my original post. The quoted sections below will be from the post mentioned above.

I’m just gonna say. I HATE labels like this… I wish doctors and psychologists would stop labeling a people as something that they feel they have to live with forever.

Love them or hate them, labels aren’t going away. In fact, I believe that labels are essential to our success as human beings. Childhood learning is full of labeling. We label, we categorize, we generalize. It helps us learn. We look at a ball learn about it. The next time we come to a spherical object, we assume it has similar properties with the first ball we saw. Labeling helps us learn.

In this case, I assume that you are referring to “Major Depressive Disorder” when you say that you “HATE labels like this.” But labeling things like this helps physicians who are treating a patient. I will be the first to say that I am not the biggest fan of the DSM-IV, affectionately known as the Bible of Psychiatry. Sometimes the labels make no sense. But more often than not, in medicine and psychiatry, labels help to dictate the next step in the management of a patient.

We don’t label for fun. We don’t call someone “obese” to be mean. Statistically, those over a certain BMI have an increased risk of unhealthy consequences down the line. We don’t differentiate between pre-hypertension, stage I hypertension, and stage II hypertension because we are bored. Knowing what kind of hypertension a person has will direct the therapy of that individual. Ideally, the delineations like these are there to help guide treatment.

A second reason for these labels is insurance purposes. But I only mention this to acknowledge it. I believe that labeling is important for the reason I’ve written above.

If you are THAT unhappy, there is someone in your environment causing it. You may even have a physical illness (undiagnosed). People will stay in the most horrible situations or with people who are constantly belittling them in some way and not see that as a source of or part of the problem. Sometimes the depressed person is doing something that he knows is wrong … or doing something someone else SAID was wrong… with the resultant self-loathing. To get up, get some balls and actually do something about one’s life takes courage and I know that when you’ve been beaten down for a long time courage is hard to come by.

Sure, there are many reasons a person might be depressed. You are correct that a physical illness can be the cause. There is a diagnosis in the DSM for that — Mood disorder due to a General Medical Condition (DSM-IV 293.83). We also have other diagnoses like “substance-induced mood disorder” or “minor depressive disorder” or “mood disorder not otherwise specified.”

But I will disagree with a blanket statement saying that if someone is “THAT unhappy” then there is “someone in your environment causing it.” It may contribute to the depression for some, but I wouldn’t call it the cause.

There are many theories as to how depression comes about. But one thing is clear — there are definite differences in the brain of a person suffering from depression. There is decreased metabolic activity and PET scans show decreased blood flow. The endocrine system is also affected; depressed patients seem to have specific dysregulation in certain hormones. This is not explained by just “someone” in the environment. There are biological differences.

I wish I could tell the depressed patients I see to grow a pair and DO something. But I can’t because it doesn’t work. Depressed people hear pleas to DO something all the time. Sometimes people need more help than a pep talk.

Life is a battle at worst and a fun game at best. Either way, it takes courage and skill and a willingness to fight or play with all your might. Change of venue, change of friends, change of husband or wife, change of attitude is much more beneficial than a label!

I agree. Life is a battle. There are ups and downs. And a change of venues/friends/spouse just might do the trick. But sometimes, change just cannot happen right away.

The last few weeks I have been on the Adolescent Psychiatry unit. What do you tell a child who is depressed and suicidal due to their own traumatic events? There are kids who have been abused. Kids who don’t have healthy parental support around them. You can’t tell them to just get up and make a change.

Life sucks. Sometimes you can’t make the changes you’d like change. And these depressed patients often need to learn coping skills to deal with the situation they find themselves it.

If you have just lost both legs in Iraq or your child has died or some other genuine horror has befallen you, then okay, I’ll give you some longish time to come to terms with it…otherwise… whatever.

I don’t know what is considered to be a “longish” time. I’ll forego putting into words my initial response to this paragraph; it wouldn’t be helpful. But Iraq was brought up. During my time at the VA, I saw old men who suffered from PTSD. These were hardened, combat veterans. Tough guys. But 30 years later, they still suffer from flashbacks, nightmares, avoidant behavior, hyper-vigilance. Labeling these proud men with PTSD is the first step in getting them the help they need. Ignoring it can be disastrous.

So you don’t like your job or you just ‘feel sad’, go to work, work hard, do something that interests you, run a marathon, create a some art but don’t label yourself and then be that the rest of your life. I know this sounds harsh but the whole label thing really bugs me.

Okay, I’m done with my rant.

Finally, if someone were only “feeling sad” and able to run a marathon, create art, and do things that are enjoyable to them… well, then by definition, that wouldn’t be Major Depressive Disorder. MDD affects a person’s daily living. Anhedonia (or lack of interest in things they used to find enjoyable) is present in nearly all adults with MDD. They don’t find anything interesting.

Now, are there people who are incorrectly diagnosed as MDD? Sure. Diagnoses evolve as we learn about a patient. And yes, I’m sure there are patients who will take their diagnoses of MDD (whether correctly or incorrectly given) and use it as a crutch. They use it as an excuse for themselves or their inactivity in life. However, I don’t think this is a problem of “labeling.” In my view, it is a problem with defense-mechanisms or coping skills. They are basically using avoidance to get out of something they find uncomfortable.

Also, and I feel bad for sticking this in at the end, I think there is a confusion with the diagnosis of MDD. A person who has one major depressive episode can technically be diagnosed with MDD. But a major depressive episode can last for as little as 2 weeks. After that time, they can be back to normal and fully functional. Others, though, will have recurrent episodes of major depressive episodes that last for months (or longer) at a time.

This has been quite the lengthy post. But essentially my points are:

  1. MDD is real. We need to be more vigilant in getting help to those who need it.
  2. Labels like MDD are useful because they help us decide on treatment. It can be quite an effective tool.
  3. Many people with true MDD will benefit from treatment.
  4. Some people do use their diagnosis as a crutch to avoid things, but the problem is not the label. The problem is poor coping skills.
  5. MDD does not mean someone always has a depressed mood. It only means they have had periods (or episodes) of major depression.

If anyone would like to add their $0.02, please feel free to do so via the Contact Me link or in a comment below. You don’t have to agree with me. And I know that some of the people I follow have battled with depression. If your experiences have been totally off, please tell me. Hearing your views will only help me be a better doctor someday.

  1. My tumblr account is usually pretty silly. It is where I post light, non-medical related posts. []
  • Bensfriends9

    WOW!! Nice post great i like it.
    Thank you for post.

  • How is the depressive phase of bipolar disorders different from a major depressive episode?

    Whether Borderline personality disorder / Bipolar Disorder are 2 different diseases?