A search Towards Finding A standard Diagnosis for Depression: A research Proposal Presented in Partial Fulfillment for a ward of a Degree in (University).
The concept of depressive disorders has become a prominent challenge for the modern generation of people. Experts believe that the peak of the development of depressive disorders occurs today, which suggests that the problem of depression should be analyzed more thoroughly. The work aims to define the less studied direction, which requires more careful analysis to contribute to the solution of the problem of depressive disorders. For this, in the paper, a series of reputable readings, which will help to make the most precise picture about this issue, will be selected and analyzed. The literature review will analyze the concept of depression, its historical development, major subtypes, symptoms, and popular treatments.
It is reported that over the past few decades, the number of patients who have complaints of symptoms that are inherent in depression has doubled (Horwitz, 2010). In addition, the fact that every second pharmaceutical product purchased is antidepressant indicates that the problem of psychological disorders is extremely acute. In the clinical sense, depression is a whole syndrome or a complex of symptoms of emotional disorders. In this regard, as a subject of particular examination and treatment, depression is extremely specific and therefore, cannot be characterized or treated universally.
It is a mistake to believe that only modern society is prone to depression. According to Thomas Ban, this disorder is known from ancient times, but only in the nineteenth century acquired the contemporary name. The history of depression dates back to BC era when Hippocrates described it by calling it melancholy (Ban, 2014). He attributed to the occurrence of this disorder on the accumulation of black bile in the body, which, he believed, occurs due to a prolonged stay of a person in fear and sadness. Only in the fifth century, melancholy was characterized as mental suffering, despondency, hostility, passive behavior and the desire to end life. After a while, what is now called depression began to be distinguished as “general melancholia, brain melancholia, and hypochondriacal melancholia” (Ban, 2014). The variety of symptoms also became wider as now it included dietary deficiency and some other emotional factor that previously was not treated as a disorder. Later, Timothy Bright divided melancholia into natural melancholia and unnatural melancholia based on Avicenna’s works (Ban, 2014). The first one was characterized by a feeling of moodiness and irritability, while the second one was treated as a severe mental disorder with features of insanity. In the sixteenth century, Robert Burton made a prominent contribution to depression diagnosis and, as a result, melancholia was divided into head melancholia, body melancholia, and hypochondriacal melancholia (Ban, 2014). Since the nineteenth century, the concept of depression began to develop rapidly. Basically, nineteenth-century literature had a similar look at the definition of depressive disorders and characterized them as anxious, hostile, and retarded. In addition, it is argued that mainly scientific literature devoted to the study of depression identified such types of depression as dysthymic, agitated, hostile, anxious, psychotic, endogenous, and neurotic (Ban, 2014). In the twentieth century, the study of depressive syndromes became full-scale. This is also confirmed by the statistics cited by Brandon Hidaka (2012) in his article devoted to the modern trends in depression prevalence. In particular, Hidaka claims that in order to understand the current epidemiology of depression, it is necessary to analyze the development trends of humanity and its adaptation features (Hidaka, 2012). For example, Hidaka’s ideas resonate with those provided by Ban. However, Ban does not give any information about depression at an earlier time. At the same time, Hidaka argues that Homo sapiens, who proved to be the most adaptive species, were less prone to depressive symptoms. This, according to Hidaka, indicates that the environment favorable for the development of this disorder appeared much later. In addition, it is claimed that to date, depression has reached that mark when it can rightfully be called a disease of modernity (Hidaka, 2012).
When trying to understand the concept of depression, one should remember that the depressive state itself is not universal. In general, several subtypes of depression are distinguished based on several criteria that include the severity of depression, the type of symptoms, and the length of the depressive state. Regarding the depth of the depression, some distinguish mild, moderate, severe forms of depression. For instance, Fava et al. argue that depressive subtypes include melancholic depression, double depression, atypical depression, depression with comorbid personality disorders, hostile depression, and anxious depression (Fava et al., 1997). It should be noted that those who adhere to the traditional classification, distinguish two types of depressive states: monopolar and bipolar depression (Judd et al., 1997). The second type is better known as manic-depressive psychosis. According to Judd et al., this disorder is called bipolar, because depressive episodes and manic episodes vary prominently. In other words, in this disorder, the mood can fluctuate by taking opposing polar forms. Bipolar depression, in turn, is divided into two subtypes: manic-depressive psychosis proper or severe type and the so-called mild form (Tofoli et al., 2011).
Based on the analysis of sources, one can conclude that the classification of types of depression is in constant development. According to Tofoli et al., this is due both to the continuous development of science and to the fact that in the modern world, depression covers an even more extensive range of manifestations and takes new positions. In addition, according to one of the classifications, there are the following types of depression: seasonal; so-called "female" depressions including postnatal depression and premenstrual syndrome; children's depression; atypical; dysthymia and double depression; pseudo-sloughing; melancholic; other depressive disorders (Tofoli et al., 2011). However, some experts believe that in order to effectively diagnose and treat depression it is not at all necessary to divide this disorder into a variety of subspecies (Klein, 2011). In particular, Daniel Klein in his article titled “Classification of Depressive Disorders in DSM-V: Proposal for a Two-Dimension System” argues that the system for classifying a depressive disorder can and should be simplified. For this, he claims that it is enough to follow only two criteria, namely the severity and chronicity of depression (Klein, 2011).
According to the medical classification of ICD-10, the symptoms of depression are divided into primary and additional. According to National Collaborating Centre for Mental Health, often, in order to be able to assert that the diagnosis is correct confidently, the individual should have at least two symptoms from the main group and three or more of the additional group. Based on the diagnostic criteria of ICD-10, depressive conditions are diagnosed if there is a presence of these symptoms persisting for more than two weeks (National Collaborating Centre for Mental Health, 2010). However, this diagnosis can be established in cases characterized by a shorter time interval, but with unusually severe and rapid onset symptoms. Furthermore, it is also claimed that “the symptoms need to be experienced to a sufficient degree of severity and persistence to be counted as definitely present” (National Collaborating Centre for Mental Health, 2010). Somatic symptoms include significant weight loss without making any effort, insomnia, psychomotor agitation, fatigue or loss of energy. It should be noted that these symptoms do not differ from those used, according to Ban, to determine depressive disorders in antiquity (Ban, 2014).
Symptoms of childhood depression have some differences. On the presence of a mental disorder in a child testify nightmares; insomnia; loss of appetite; decline in academic performance. Based on the diagnostic criteria for ICD-10, depressive conditions are also diagnosed if there is a presence of these symptoms persisting for more than two weeks. However, according to National Collaborating Centre for Mental Health, the diagnosis can be established in cases with a shorter time interval if there are unusually severe and rapidly advancing symptoms. In medical practice, the criteria for determining the disease, proposed by another medical classification system, namely DSM-IV-TR. According to this system, a depressive condition is diagnosed if for two weeks there are five or more symptoms out of nine, and, like in the previous classification, the symptoms of the disease should include at least one of two main signs - loss of interest or depressive mood.
One of the reasons for the extensive list of classification of types of depression is an attempt to predict a correct drug treatment depending on the characteristics of the depressive disorder. This topic is well disclosed in Fava et al. who devoted an entire article called “Major Depressive Subtypes and Treatment Response” to the issue of depression treatment (Fava et al., 1997). The goal of the article is to find the relationship between major subtypes of depression and their response to antidepressant drugs, in particular, fluoxetine. In fact, drug treatment of depressive disorders is a rather popular practice. Effective treatment of depression lies in a thorough study of the causes and conditions of its occurrence. This requires the use of special techniques and appropriate professional qualification, depending on the severity, duration, and chronicity of depression, it is necessary to apply different types of treatment (National Collaborating Centre for Mental Health, 2010). The appointment of such drugs is the responsibility of psychiatrists involved in the diagnosis and treatment of mental disorders. Specialists should independently determine the expediency of using this group of pharmaceuticals, supervising their use, taking into account the ratio of the harm and benefit factors, as long as the competent selection of doses. That is why the topic of drug treatment is so widely covered in the scientific literature. For example, both articles by Fava et al. and National Collaborating Centre for Mental Health report about treatment-resistant features of some depression types. Moreover, an interesting idea regarding the treatment challenges is suggested in the article by Tofoli et al. in their article “Early life stress, HPA axis, and depression” (Tofoliet al., 2011). There, authors claim that the root of the issue lies in neurobiological peculiarities of the disorders. In addition to pharmacological medical treatment of depressive disorders, one should not remember about psychological support which can be applied both simultaneously with pharmaceutical, and separately. In addition, Allan Horwitz cites a rather prominent idea that pharmaceutical companies mainly impose the popularization of antidepressants, and in some cases, their use is entirely unjustified (Horwitz, 2010).
During the source analysis, a gap, which was not sufficiently covered, in all of the readings has been detected. The gap lays in depression diagnosing, as the link between depression and genes is not sufficiently revealed yet. The lack of a valid classification system as practical and significant clinical ramifications, especially in primary care contexts where there is a high likelihood for a full range of depression presenting themselves. Due to confusion on how depression should be diagnosed, clinicians often grapple on whether or not to use anti-depressants treat or not treat, refer the patient for further assistance among others. These conflicts necessitate a formulation of standard criteria for conducting a depression diagnosis which takes into account specific factors such as the patient’s perspective on the cause of symptoms, relevant treatment and hence provide an effective categorization and diagnosis criteria which captures the inherent complexity accordingly. Therefore, it is evident that the challenge requires a more in-depth analysis and further investigation.
This research will employ both primary and secondary research methodology. Accordingly, the researchers will undertake an interview with 20 subjects who are presenting undergoing depression treatment at two public health facilities in New York City, the Metropolitan, and, the New York City Health. The main questions which the respondents will be asked include their experiences while being diagnosed with depression and associated treatment. The researchers will also focus on identifying barriers to diagnosis, their comprehension of depression alongside information issues pertaining to treatment options. After discussing with the administration of the respective hospitals, we will request for records for patients who are booked for depression within the last six months. The selection criteria will, therefore, be purposeful driven and such respondents must be in a position of speaking English. They must as well be in a position of giving informed consent for them to be eligible for the study. We will as well seek approval from our University Institutional Board.
Semi-structured qualitative interviews that will last approximately 40 minutes will as well be used to obtain information from the 20 subjects presently under depression treatment and 5 clinicians dealing with depression issues. Two members of the research will be involved in interviewing the respondents with one directly involved in the interviewing while the other will be taking notes. The primary interviewer was required to maintain eye contact with the subject. The transcripts will be checked for consistency and later merged. The set of questions in the interview includes the experiences of the subject, their attitudes, and observations on the diagnosis process, how they received information pertaining to the diagnosis and their treatment experiences. There will be an adequate probe to each subject to retrieve sufficient details from the responses provided. Subjects will further be required to talk about their present episode of depression and other ailments if any. The questions to be asked are presented in the appendix section.
Secondary data will also be relied on in augmenting the research pertaining to the diagnosis of depression. In this respect, the researchers will look at criteria that have been deemed to be effective and compare them with others that have been used so far. Key databases that will be used for this course include Medline, Academic search premier, Emerald, EBSCOhorst, Proquest, and Google. This will help in achieving the goal of formulating a more effective and standardized strategy to diagnose depression in a more appropriate manner.
It is hoped that findings from this study will help in addressing the inherent shortcomings pertaining to diagnosis and treatment of depression. Filling this gap and hence; achieving the purpose of this study will work a great deal in promoting patient-centeredness of care as it relates to the depression disorder. Furthermore, this research and subsequent analysis will provide a potential for a positive treatment outcome as well as engagement for depression patients and clinicians.
We acknowledge the existence of limitations to this particular study. Among these is the difficulty associated with the classification of depression in a correct way. This problem could in a perspective lower the proportion of established cases of depression in the study. Additionally, the problems associated with differential diagnosis makes it hard to determine the exact level of depression among each patient. This owes to the fact that depressive experiences differ from one person to another. On the other hand, due to the sensitivity of the patient information, we do not intend to utilize clinical records of the patients involved in the study. Therefore, we will only obtain verbal information from the subjects and the physicians involved. This means that depressive symptoms which may be only secondary to the primary mental disorders may easily be labeled as depression. However, in avoiding this dilemma, we will request the responsible clinicians to direct us to only the appropriate cases.
There is also a likelihood of selection bias, considering that purposeful sampling criteria will be used in choosing the subjects. This is meant to obtain only respondents who are affected by depression and undergoing treatment for the condition. However, we will endeavor to prevent this bias by putting a special care not to inform the participants concerning the aim of the research. This is aimed at avoiding participants who may be embarrassed by participating because of not being clear of their condition.
To summarize, the primary goal of the research is to establish a standard form of diagnosis for the depressive disorder. A distinctive feature of this work is the fact that it represents an in-depth research of the issue while critically evaluating the information presented and comparing it with other literature that reveals the issue of depression. During the literary analysis, several reputable sources containing exhaustive information on a particular topic were identified. During the source analysis, a gap, which was not sufficiently covered, in all of the readings has been detected. The gap lays in depression diagnosing, as the link between depression and genes is not sufficiently revealed yet. Therefore, it is evident that there is a need for a more standardized formula to diagnose depression and hence provide effective treatment option. The challenge requires a more in-depth analysis and further investigation.
Ban, Ta. "From Melancholia to Depression: A History of Diagnosis and Treatment." International Network for the History of Neuropsychopharmacology. http://inhn.org/fileadmin/previews_new/From_Melancholia_to_Depression_March_6_2014.pdf
de Carvalho Tofoli., Baes, Von., Martins, Camilla., &Juruena, Mario. “Early life stress, HPA axis, and depression”. Psychology & Neuroscience, vol.4, no.2, 2011, pp. 229-234
Fava, Maurizio et al. “Major depressive subtypes and treatment response”. Biological Psychiatry, Volume 42, Issue 7, 1997, pp.568-576,
Horwitz, Allan. “How an Age of Anxiety Became an Age of Depression”. The Milbank Quarterly. Vol. 88, no,1, 2011. Pp. 112-138.
Hidaka, Bithaka. “Depression as a disease of modernity: explanations for increasing prevalence”. Journal of Affective Disorders, Vol.140, no, 3, 2012, pp. 205-214.
Klein, Daniel. “Classification of Depressive Disorders in DSM-V: Proposal for a Two-Dimension System”. Journal of Abnormal Psychology, vol,117, no, 3, pp.552–560.
National Collaborating Centre for Mental Health (UK). Depression: The Treatment and Management of Depression in Adults (Updated Edition). Leicester (UK): British Psychological Society; NICE Clinical Guidelines, No. 90. 2010.
Appendix: Interview Guide for the Respondents
How were you diagnosed?
3.How did you understand depression prior to being diagnosed
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