Earlier this year, I faced a radical change in my life that involved a separation and a relocation 2500 km away from what I call home. Despite a mutual understanding and knowing that this was the necessary next step for further relevant growth, it was hard and painful. I felt loss and a vast amount of sadness; I was deeply confused; my concentration dropped; I felt exhausted and there were moments when my confidence about the made decision 'went on holiday' when they were needed most.
If I had gone to a doctor at this stage in my life, I would very likely have been diagnosed with depression and offered medical treatment. You might think that this makes no sense, as it is obvious that my pain was strongly related to the situation, I was in. However, the fact is that a particular life situation or circumstances do not qualify as primary factors for a diagnosis. You may wonder what a diagnosis is based on if not a patient's very personal life history and life situation. Good question.
Well, who is diagnosed with what is defined by the International Classification of Diseases (ICD). The ICD system is used by the UK and other members of the WHO. However, British psychotherapists and psychiatrists often consult the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-5 (Diagnostic Statistical Manual, Issue 5) is a thick, blue book written, monitored and regularly updated by the American Psychiatric Association (APA). The DSM is essentially based on the ICD published by the World Health Organisation (WHO). For the purposes of this column, I will refer to the DSM-5.
So, let's take a look at this 3.31-pound (1.5 kg) colossus of a manual. The DSM-5 contains the following criteria for the diagnosis of depression:
The person must have five or more symptoms within the same two-week period, and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.
Depressed mood most of the day, nearly every day. (Check!)
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. (Yep!)
Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. (Oui.)
A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down). (Kind of, yes.)
Fatigue or loss of energy nearly every day. (Yes, a bit, I’d say.)
Feelings of worthlessness or excessive or inappropriate guilt nearly every day. (Nope.)
Diminished ability to think or concentrate, or indecisiveness, nearly every day. (Totally!)
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. (Nope.)
Let me add that up. So that's 6 out of 5 necessary symptoms to diagnose depression with medical treatment. Does this mean that I suffered from a depressive disorder? Clinically speaking - yes. Personally speaking - no.
My perceived pain, confusion and irritation were not a disorder but a consequence of the life situation I was in. I am confident that you too have felt this way at some point in your life, and I am equally confident that you too had reasons for it, even if they were not as obvious as in my case.
Did you know that around 1 in 6 adults in the UK currently suffer from "moderate to severe depressive symptoms"? (Data was collected for the period 29 September to 23 October 2022). Accordingly, the number of antidepressants prescribed has increased by 35% since 2016 - from 62.9 million in 2015/2016 to 83.4 million in 2021/2022.
These are shocking figures. But are they really shocking you? Do you feel a deep shock when you read that 83.5 million antidepressants were sold to a population of 67.5 million people? Or have you got used to the fact that antidepressants are a part of our society? Maybe you know someone - your neighbour, friend, colleague, partner or yourself - who takes antidepressants regularly/semi-regularly. Today, 1 in 4 workers in the UK meet the criteria for 'clinically relevant depression' and are eligible for drug treatment. That's 10 people in a small company with only 40 employees. That's a lot, isn't it?
The number of diagnoses and prescriptions is one problem; another is the duration of prescribed treatment. While the general duration of drug treatment is six months, many people diagnosed with depression continue to take antidepressants for months or even years after their "symptoms" have subsided. This so-called maintenance therapy aims to reduce the risk of a "depression relapse". Here, I refer to the formulation used by the UK's National Institute for Health and Care Research, which I disagree with because it assumes a particular set of feelings that are "right" and "wrong" and implies that the symptoms that describe depression are problematic and should be avoided. - Just like alcohol, narcotic substances and other forms of intoxicants. Yet, there are no harmful emotions that we have to avoid. However, we have to learn how to relate to difficult emotions and pain in a helpful, growth-promoting and safe way. Sadly, the understanding of a ‘depression relapse’ does not encourage such an approach.
Looking at the epidemic proportions of diagnosed depression, the question arises about the social responsibility involved. But that is not what I want to talk about today. Today I want to talk about our pain, our sadness, our despair, our lack of motivation and our confusion. I want to talk about the so-called "symptoms" of depression and how we face (or avoid) them.
While a diagnosis of a depressive disorder can give people relief - "Ah, that's why I feel so bad" - it also takes away something priceless. It takes away our ability:
- to be curious about our pain
- to really understand the source of our pain
- to accept our pain
- to take responsibility for our pain
- to process our pain
- to move through and let go of our pain
- to change and become more comfortable with ourselves
The problem with a diagnosis of depressive disorder is that we often abdicate responsibility to a medical disorder. We no longer patiently ask about our own role, our responsibility and what makes us feel down, uninvolved, lonely or sad, but retreat to the fact that we have an illness - we have depression, and we accept medication as the main remedy.
However, if I take my personal experience as an example, then I can't see how a booster of SSRIs (Selective Serotonin Reuptake Inhibitors) - antidepressants - would have really helped me in my life situation. It was hard and painful, yes, yet, I needed my pain to understand my process, my own needs, my loss and my newfound perspectives. All the despair, chaos, sadness, disorientation and pain were needed. I needed to listen to them in order to make sense of them and to grow with and through this invaluable life situation.
As so often, it boils down to the question: do you trust your organism? Do you trust it to work in your favour? If yes, then perhaps your organism is trying to tell you something through your difficult feelings and experiences, rather than deliberately harming you and working against you. So, I encourage you more than ever:
Listen to your pain. You need your pain.
...AND WHAT IS YOUR EXPERIENCE?
Do you remember a moment in your life when you felt low over various days, weeks or even years? Did you understand why you feel the way you feel? How did you facilitate and support yourself through this process? Did you avoid or welcome your pain? Did you distract yourself from feeling pain or did you face it?
A safe, non-judgmental therapeutic space in which you can share yourself and explore your difficult feelings and circumstances can be of invaluable power. I encourage you to attend to your pain, even if it hurts.
National Institut for Health and Care Research: https://evidence.nihr.ac.uk/alert/almost-half-people-long-term-antidepressants-stop-without-relapse/
NHS, SSRIs: https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/ssri-antidepressants/overview/
Pharmaceutical Journal: https://pharmaceutical-journal.com/article/news/antidepressant-prescribing-increases-by-35-in-six-years PsycomNet: https://www.psycom.net/depression/major-depressive-disorder/dsm-5-depression-criteria
Very Well Mind, ICD-11: https://www.verywellmind.com/overview-of-the-icd-11-4589392
Very Well Mind, DSM-5: https://www.verywellmind.com/dsm-5-and-diagnosis-of-depression-1066916