Depression. Straightforward, or is it?

Depression is the most commonly diagnosed mental health condition, and the majority of cases are diagnosed by a family physician. It seems straightfrorward; you feel depressed, have a hard time accomplishing what you want to, and your relationships suffer. Your doctor has given you an antidepressant, and it doesn't seem to do much for you, so you try another. This time you feel worse. Your doctor refers you for counseling, which helps a bit, but you are still struggling.

This story is all too familiar. Depression isn't just depression. The trouble is, many people diagnosed with depression aren't depressed, at least not in the way that an antidepressant would help with. One of my pet peeves as a therapist is the confusion regarding depression, because of an issue called "Symptom Overlap." This means that symptoms in different disorders can be the same as symptoms in other disorders. Unfortunately, diagnostic tests are not available to identify the causes of the symptoms, so we play a game of trial and error.

There are several categories of depression in the DSM (Diagnostic and Statistical Manual), the guide used by most practitioners in North America to diagnose. There is much critique with how depression is dealt with in the DSM. People who feel depressed can actually experience a number of different "disorders" such as Major Depressive Disorder, Atypical Depression, Seasonal Affective Disorder, and Bipolar II. The root cause of these labels differs with three general causes. Serotonin, Dopamine, and Light.

Serotonin is in play when you feel sad, have trouble staying asleep, lose your appetite, and consistently stay depressed even if something good happens. This type of depression usually responds well to a SSRI (Sustained Release, Serotonin Reuptake Inhibitor) antidepressant.

However, if you have trouble getting out of bed in the morning, feel irritable, have an increased appetite, experience sensitivity to rejection, and experience mood improvement, briefly, when good things happen, you are likely experiencing Atypical Depression, which is related to the neurotransmitter Dopamine. An antidepressant will usually not help as it is working on a different neurotransmitter. None of the antidepressants on the market focus primarily on Dopamine. An older class of drugs, not commonly used, MAOIs (Mono-Amineoxidase Inhibitor) do effect dopamine, but there are serious potential side effects and dietary restrictions due to a reaction with tyramine, present in aged cheeses and wine, for example.

To make this more complicated, the frequency and timing of these "atypical" symptoms changes the diagnosis. If they happen only in winter, we call it SAD (Seasonal Affective Disorder).  Treatment is with natural light, but there is very high comorbidity with ADHD, another Dopamine based disorder.  If the symptoms are episodic, any time of the year, we call it Atypical Depression. If the symptoms are cyclical, with occasional hypomanic symptoms, we call it Bipolar II. Confused yet? Many of us are, with good reason. Adding confusion is the fact that we now know that anxiety and ADHD are highly comorbid with depression, as are issues with substance abuse. 

So where do we start? We need to look bigger, rather than right in the moment. We need family history, as these conditions run in families, and other family members experiences with what does and does not work helps guide us. Secondly, onset of symptoms, and the number of, and pattern of relapses helps narrow down diagnosis. Onset in childhood or adolescence separate from trauma suggests Dopamine, rather than Serotonin.  Third, we need to be open to trial and error. A combination of counseling and medications are often needed. We can effect our Serotonin levels through lifestyle changes much more easily than we can effect Dopamine levels. Therapy is a key component in recovery, regardless of the diagnosis.

I will go into more detail in subsequent blogs, as there is a lot of detail to clear up, but this gives an overview of one of the biggest areas of confusion in Mental Health diagnosis. When you meet with us, and you tell me things didn't work, I believe you! There is plenty of reason to see why people struggle with recovery.