By David W. Goodman, M.D.
Clinical Instructor in Psychiatry
The Johns Hopkins University School of Medicine

Although at first glance this subject may appear to be simple, in my experience as a psychiatrist, it is not. Although most readers of this newsletter are well acquainted with the symptoms psychiatrists use to diagnose depression, a person experiencing depression often doesn't realize that he or she is depressed.

The patient's difficulty in identifying his or her own depression results from a number of factors. First, and very important, is the time it takes for symptoms to emerge. It would certainly be easier to identify a depression that developed in 24 hours than one that developed slowly and insidiously, over weeks or months. Because of the slow change in mood, patients tend to "psychologize" (make uninformed psychological speculations about) their depression, attributing it to chronically stressful circumstances. That is, they "explain their depression away" on the basis of relationship conflicts, job pressures, or economic difficulties, for example.

Another factor in misidentifying depression is the assumption that it is caused by a painful event. Often you'll hear someone say "I can certainly understand why you're depressed, given what just happened" (referring to such an event), or "I'd be depressed if that happened to me." Such statements are meant to be supportive, but equating sadness with depression may divert the patient from identifying the depression.

A third factor is denial of one's depressive disorder. (In the presence of a limitation or impairment, including depression, denial as a psychological defense is often useful in promoting a higher level of functioning, but it may prevent the person from identifying treatable symptoms and seeking optimal care.) Family members or close friends may participate in denial of the illness. They unintentionally hinder a patient's identification of depression by such remarks as "You're just having a bad day. Everyone has bad days." It is often crucial to educate family members and significant others about depression and about observable changes which may indicate a depressed state in the patient in question. This education should result in everyone's being able to distinguish "a bad day" (sadness/demoralization/frustration) from depression (a psychiatric illness).

After being diagnosed with depression, a patient may become uncertain about his or her own moods. "What's a normal emotional reaction and what's not?" "How do I know whether I'm depressed or just sad?" Because this uncertainty also contributes to the delay in identifying depression, patients should be taught to distinguish the qualitative differences in their moods by focusing on specific symptoms or experiences.

Each individual's depressive experience has its own rate of progression, with very specific symptoms. The treating psychiatrist is best able to elicit a recounting of these symptoms when the patient is having an acute depressive episode. I find the symptoms occurring at this time particularly important because they become my reference point for evaluating the patient in future mood states. I come to rely on them to help distinguish depression from sadness.

To help my patients identify a depressed mood, I list their specific symptoms for use as a checklist. A detailed list includes 10 to 15 symptoms with which to track the patient's mood state from the blahs to clear depression. The guidelines for these symptoms can be taken from, but need not be limited to, the diagnostic criteria for major depression and dysthymia in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Patients should refer to the checklist two or three times a week, regardless of their mood state. They learn that in a euthymic (normal) mood state, they may have 5. In a depressed state, however, they may have 10 to 12 of the 15 symptoms. Thus the checklist is useful not only to identify a depressed state, but also to document the significant reduction in number of specific symptoms when a patient is merely sad or the near absence of specific symptoms when the patient is euthymic.

The checklist becomes even more important when mood states seem to be related to events. Often a patient will tell me, "I'm depressed because I had a fight with my boss." The patient's description, however, may not clearly reveal whether the conflict was legitimately based in work issues or was actually precipitated by the irritability of the patient during an unstable mood state. Going through the symptom checklist can help to identify a depression before we try to explain the depression. If a person is depressed, for whatever reason, the depression itself should be given priority; then, when the depression is reduced, a review of the apparently causal event's meaning can be undertaken. To reverse this sequence may be like putting the cart in front of the horse.

"What do I do if I review my checklist and conclude I'm depressed?" I tell my patients that if a depressed mood persists for four to five days, with each day worse than the previous day, they should contact me for evaluation for possible medication adjustment. Breakthrough depressive episodes lasting one to three days may occur spontaneously while patients are on medication. If these breakthrough episodes are only occasional and tolerable, no immediate change in medication may be needed. If they are frequent and increasingly intense, control of the mood disorder is probably inadequate and the patient may benefit from a change in the medication or from psychotherapy addressing coping skills for specific events.

I hope that the above information can give patients who have a depressive disorder a better sense of control over their depression. I also encourage them to review the information with their treating psychiatrist or psychotherapist to see how it may benefit their care and treatment.