- The Key Elements of Depression
- The Interview Begins: Why Was I There?
- The Most Pressing Concern: Suicidal Thoughts? or A Plan?
- The Duration of My Symptoms
- Low Mood and Loss of Pleasure
- Impairment and Clear Physical Affects
- Other Possible Causes for My Symptoms
- 5 or More Affects or Symptoms Out of 9
- Information Only
Today, I continue the series “What Is Depression?”. We’ll explore the patient interview which led to my initial diagnosis of depression.
The Key Elements of Depression
To refresh your memory, the key elements of Major Depressive Disorder (Depression) are:
- impairment in functioning over the entire duration;
- a lack of a physiological or general medical cause;
- clear physical affects that are more than mood;
- the presence of five (or more) affects throughout the entire duration which must include either depressed mood or loss of interest or pleasure; and
- suicidal thoughts with or without a plan.
But first a note about timing. Even though I’d attempted suicide on September 2, 2014, I wasn’t diagnosed immediately. The diagnosis came many weeks later.
The Interview Begins: Why Was I There?
My interview began, as most interviews do, with an inquiry about why I was there. I explained that I’d attempted suicide a short time ago, that I didn’t yet have a psychiatrist, and that I wanted to know what was wrong with me. In addition, I explained that I sought treatment and wanted to better care for myself.
I disclosed that while I didn’t have a plan, suicidal thoughts were still present.
This forthrightness breaking the ice, the full interview began.
The Most Pressing Concern: Suicidal Thoughts? or A Plan?
The interview explored my attempt in detail, specifically
- for how long had I wanted to end my life?
- what was my plan?
- what method did I use?
- how was I found?
I answered each question openly and honestly. I believed that only honesty would get me the treatment that I needed.
The interview also explored my ongoing thoughts about suicide. Several times I was asked if I had a plan and if I still wanted to end my life. The answer was a definitive no but had I answered differently, I have no doubt that I’d have been committed.
Satisfied that no danger currently existed, the diagnostician continued with the interview. Already he had a sense of what might be the issue. We moved on to the question of duration, how long I’d been feeling like I did.
The Duration of My Symptoms
The formal definition of Major Depressive Disorder provides that your symptoms must exist for two weeks on a near 24×7 basis. Why two weeks? Simply put, Major Depressive Disorder is a chronic illness. It’s the second leading cause of disability in the United States. It’s a leading cause of disability in Canada (and the world). Forty percent or more sufferers will consider suicide of which ten percent will succeed. This translates to nearly four thousand deaths each year in Canada, forty-five thousand deaths in the United States, and one million deaths globally. In Canada, it’s believed that there are twenty-five attempts for every death by suicide.
Consequently, a balance is struck between everyday bouts of sadness, what people often mistakenly call depression, versus the chronic nature of the illness. Everyone has bad days or feels blue from time to time. That’s just a part of everyday life. Thus, the definition tries to allow time for these everyday moods to pass. But not so much time as to place someone in peril.
The typical depressive episode lasts 6 months. Many, mine included, can last years.
The interview inquired into how long I’d been depressed. Some of this information had already been elicited when we spoke of suicide. That, I found, was common. Questions were asked more than once in different forms. This was to determine my veracity since most of the information I gave was anecdotal.
My pre-attempt thoughts of suicide were in place for months so this duration alone satisfied the definition. But the depression that gave rise to those thoughts lasted for at least two years, if not longer. A diagnosis of depression seemed correct but there were other criteria still to be met.
Low Mood and Loss of Pleasure
The interview inquired into low mood and loss of pleasure. In my case, the two seemed to go hand in hand with the low mood causing a loss in pleasure which led to low mood, and so on. Or a loss in pleasure causing low mood which led to a loss in pleasure, and so on. Both in an escalating downward spiral.
How was my loss of pleasure manifested? I stopped reading, going for walks, and worst of all, spending time with my son. I lost all motivation finding it difficult to do, well, anything.
My low mood was an overriding sense of despair, a gloom, a bleakness that just was. I grew into a state that was beyond numb. I couldn’t shake it no matter what I did, which only added to the low mood.
Impairment and Clear Physical Affects
Here, as in the rest of the interview, the given answers are anecdotal. This can mean that they’re unreliable. Third parties, family and friends, doctors, etc, may be approached for verification.
The given answers create a baseline for normal functioning and the divergence from it.
I was closely observed throughout the interview:
- Is posture erect and alert? Are the shoulders slumped? Is the head down?
- Are answers clear and articulate? Is speech slow? Is there hesitation in reply?
- Are the eyes open and clear suggesting alertness, or do they seem dull and vacant?
- Is there attentiveness throughout the interview? Are answers precise? Do answers wander?
Through observation, affects are compared to the anecdotal evidence to give it credence.
In my case, my answers were sometimes unfocused, wandering away from the question. Moreover, I struggled to remain alert. I responded as fully and openly as possible but as the day progressed, my attentiveness and comprehension waned and I grew tired. I often asked that questions be repeated or explained.
Other Possible Causes for My Symptoms
The diagnostician asked about:
- substance abuse;
- a physical condition, like sleep apnea, that may be the root cause;
- bereavement or grief over a loss;
- another mood disorder (bipolar disorder, etc.).
The goal is to be precise in diagnosis so that the proper treatment can be provided. Comorbidity, that is, having two or more mental illness issues (like addiction and depression), requires a different treatment regime than only depression.
In my case, while I do have sleep apnea, it was clear to the diagnostician that my depression wasn’t solely the result of that condition. I didn’t understand what mania or hypomania were so an initial diagnosis of bipolar or bipolar II disorder was not given. This isn’t unusual.
5 or More Affects or Symptoms Out of 9
The interview was quite comprehensive and lasted some three hours. It explored my medical history, family history, employment history, social interactions, and more. It was deliberately long enough to enable the diagnostician to assess the number of affects I exhibited. Once again, the affects are:
- Depressed mood;
- Markedly diminished interest or pleasure in all, or almost all, activities;
- Significant weight loss when not dieting or weight gain;
- Insomnia or hypersomnia;
- Psychomotor agitation or retardation;
- Fatigue or loss of energy;
- Feelings of worthlessness or excessive or inappropriate guilt;
- Diminished ability to think or concentrate, or indecisiveness;
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
In my case, I ticked off all 9 boxes.
A necessary part of the interview is patient honesty. Lies or omissions can lead to a misdiagnosis that might worsen your health. It’s possible that you may not want to admit the severity of your symptoms, however, I believe that lack of openness can lead to greater harm.
In this post, I tried to give you a sense of the patient interview and what the diagnostician is investigating. In my next post, I’ll continue this series and my exploration of the definition of Major Depressive Disorder by showing you how it all fits together. To do this we’ll look at a patient history, my history.
I remind you that I’m not a mental health professional. I live with Major Depressive Disorder and, from time to time, I experience depressive episodes. The most recent depressive episode resulted in a suicide attempt. This prompted my reaching out for help. My own research, the guidance and lessons shared by peers with lived-experience, the compassion of therapists, and so much more, have all inspired me to share what I’ve learned with you. It’s information. not a diagnosis.
If you believe that you’re in need of help, I urge you to speak to your family doctor. If you’re experiencing suicidal thoughts, SEEK HELP IMMEDIATELY BY DIALING 911 OR VISITING YOUR LOCAL HOSPITAL EMERGENCY ROOM.
Learn more about obstructive sleep apnea.
Image by KotaroBlog from Pixabay