PROBLEM: Over the course of 20 years, according to the most recently available data, the U.S. saw a 400 percent increase in antidepressant use, resulting in 11 percent of Americans over the age of 12 taking some form of depression medication by 2008. Debate rages between those who believe that increased diagnoses mean we are turning normal human experience into a disease, and those who push for increased awareness of a very real psychological illness. Depending on who's doing the arguing, people are either being treated or are suffering in excess.
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METHODOLOGY: Ramin Mojtabai of the Johns Hopkins Bloomberg School of Public Health looked at a national sample of 5,639 participants who had been diagnosed with depression by a clinician in a non-hopital setting between 2009 and 2010. In face-to-face interviews, the participants were all re-evaluated for major depressive disorder (MDD) as defined by the Diagnostic and Statistical Manual (DSM). To meet the official criteria, they had to have experienced a major depressive episode -- defined as a debilitating depressed mood or loss of interest in daily activities for a least two consistent weeks -- in the past twelve months.
RESULTS: Only 38.4 percent of participants who had been diagnosed with depression by their doctor were judged in the re-evaluation to have had a major depressive episode in the past year, and thus, in the author's opinion, to actually meet the criteria for MDD. Those participants were more likely to have "probable severe mental illness" and to report thinking about or attempting suicide. The discrepancy was more prominent among older adults: for those 65 or older, only 14.3 percent met the criteria. Participants with higher levels of education, who were out of the workforce, who were divorced or separated, or who believed themselves to be in poor health were more likely to have what were judged to be correct diagnoses.
Of the 61.6 of participants who did not meet the criteria for MDD, 42.7 percent did qualify as having had depressive symptoms at some point in their life, in the form of either an earlier major depressive episode or what would be diagnosed as minor depression.
Although the people whose diagnoses were not confirmed by the study reported feeling less distressed and impaired, and used fewer services, almost 75 percent of all the participants reported using prescription medications to manage their symptoms. Even excluding the people with some depressive symptoms, the majority of remaining participants with unconfirmed diagnoses -- 69.4 percent -- had used antidepressants.
IMPLICATIONS: The diagnosis of mental disorders can certainly be subjective; because of that, it's often impossible to say with certainty whether or not someone's diagnosis is "correct." Mojtabai writes that more than anything else, these findings may reflect doctors' uncertainty about ambiguous diagnostic criteria. But especially when medication is involved, while we don't want to devalue people's suffering, we also don't want to be too quick to throw pills at problems for which better, non-medical solutions may exist.
"Clinician-Identified Depression in Community Settings: Concordance with Structured-Interview Diagnoses" is published in Psychotherapy and Psychosomatics.