Navigating Depression Diagnosis and Treatment: Challenges and Strategies

Depression, or major depressive disorder (MDD), is a serious mental health condition that can cause symptoms like persistent sadness, loss of interest in daily activities, and changes in appetite, sleep, and concentration [2]. Symptoms of depression can range from mild to severe and can significantly impact daily functioning and overall quality of life. Nearly 30% of adults will experience depression at some point, yet many suffer in silence without seeking help or receiving a depression diagnosis [2]. Alarmingly, roughly 60% of adults with depression seek professional treatment [6]. 

Depression can be challenging because its symptoms can vary widely from person to person and often overlap with other health conditions. In this guide, we’ll discuss the challenges of diagnosing depression, describe key types and their criteria, and explain the detailed process used for assessment according to DSM-5 standards. By understanding these elements, you can better recognize when to seek professional help and explore effective treatment options.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are several different types of depression, each with its own distinct set of symptoms.

There are a lot of myths out there about what depression is and also what it isn’t. It’s important to separate fact from fiction when it comes to this mental disorder so that you can better understand it and seek out the help you may need.

Here are some facts about depression, according to the DSM-5:

• Depression is a serious mental illness. It’s not just feeling “down” or “sad” for a few days. Depression is a persistent feeling of sadness, hopelessness, and/or fatigue that lasts for weeks or even months.
• Depression can affect anyone at any age. It is not discriminate.
• There are different types of depression, each with its own set of symptoms. The most common types of depression are major depressive disorder, persistent depressive disorder (also known as dysthymia), premenstrual dysphoric depressive disorder, and substance/medication-induced depression.
• Depression is caused by a mix of genetic, biological, psychological, and environmental factors.
• Depression is treatable. There are a variety of ways of treating depression, including medication, psychotherapy, and/or lifestyle changes.

What is the DSM-5?

First of all, what is the DSM-5? The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the standard classification of mental health conditions used by mental health professionals in the United States. It is used to diagnose and classify mental diagnoses. The DSM-5 was published in 2013 by the American Psychiatric Association (APA).

This publication is important because it provides a common language and standard criteria for the diagnosis of mental conditions. This manual is used by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, and policymakers.

How is the DSM 5 Used?

The DSM-5 is used to diagnose a mental disorder. It provides a set of depressive symptoms and criteria that must be met in order for a diagnosis to be made. The DSM-5 is also used to guide effective treatment.

For example, if a person is experiencing symptoms of a severe form of depression, the DSM-5 can be used by providers to help determine whether or not they meet the criteria for a diagnosis of depression. If they do meet the criteria, the DSM-5 can then be used to guide treatment. This might include medication, psychotherapy, or lifestyle changes.

What is severe depression, according to the DSM-5?

Depression, in its simplest definition, is a mental and mood disorder characterized by a persistent feeling of sadness, hopelessness, and/or fatigue. However, according to the DSM-5, there are different types of depression, each with its own set of symptoms.

Signs and Symptoms of Depression

Depression symptoms can vary widely from mild to severe and may present differently in each person. It’s almost important to note that if you don’t meet enough symptoms to be diagnosed with major depression that doesn’t mean you’re not suffering from depression. A therapist or psychiatrist can still help manage your symptoms. 

Psychological Symptoms: 

These emotional symptoms, if present most of the time and affecting daily life, are key indicators of depression [2]: 

• Persistent sadness or irritability 
• Loss of interest in activities once enjoyed 
• Feelings of worthlessness, hopelessness, or guilt 
• Difficulty concentrating or making decisions 

Physical Symptoms: 

Physical symptoms often accompany depression and can significantly interfere with daily functioning [2]. 

• Changes in appetite or weight 
• Sleep issues 
• Low energy or fatigue 
• Restlessness or slowed movements 

Additional Considerations: 

Unexplained aches, chronic pain, and other physical complaints can sometimes signal depression, especially when no clear medical cause is identified [2].

Challenges in Diagnosing Depression 

Diagnosing depression can be particularly challenging due to a variety of factors. Here are some of the key challenges: 

• Wide Range of Symptoms: Depression can manifest in many different ways, from psychological symptoms like persistent sadness and irritability to physical symptoms such as changes in appetite and sleep disturbances. The DSM-5 lists numerous symptom combinations for major depressive disorder, which adds to the complexity of creating a consistent diagnostic profile [9,10,14]. 
• Overlap with Other Conditions: Depression often coexists with other mental health issues and physical illnesses, making it difficult to pinpoint which symptoms are attributable to depression and which are due to other conditions [4,10]. 
• Variability by Person: The presentation of depression can vary widely among individuals and may change with age or over time. For instance, symptoms in children may differ from those in adults or even symptoms between men and women, and the experience of depression can evolve [9]. 
• Reliance on Patient Reports: Diagnosing depression largely depends on patients communicating their feelings and experiences to clinicians. Unlike some medical conditions with clear diagnostic tests, depression lacks objective markers, leading to variability in how diagnoses are made [10]. 
• Limited Time in Primary Care: Primary care physicians may have limited time to conduct comprehensive evaluations, potentially leading to missed or delayed diagnoses [8]. 
• Stigma and Hesitancy: Social stigma and personal hesitancy can prevent individuals from discussing their mental health issues openly, making it harder to identify and diagnose depression [8]. 
• Overlooking Depression: When patients have other medical conditions, their depressive symptoms may be mistakenly attributed to these conditions rather than recognized as a separate issue [4]. 
• Unclear Biological Causes: The precise biological causes of depression are not fully understood, which complicates the development of definitive diagnostic tests. Consequently, diagnosis often depends on symptom assessment rather than clear biological markers [10].  

What are the different types of depression?

There are many different types of depression, each with its own set of diagnostic criteria. The DSM-5 outlines these categories to help differentiate and accurately diagnose the various forms of depression. Here’s an overview of each type and what distinguishes them. 

Depression, a persistent mood disorder marked by sadness and disinterest, is categorized into several types according to the DSM-5. These include [6, 12]: 

• Disruptive Mood Dysregulation Disorder: Characterized by severe temper outbursts that are out of proportion to the situation and a consistently irritable or angry mood. 
• Major Depressive Disorder (MDD): Defined by a persistent low mood and loss of interest in activities, with additional symptoms such as changes in sleep, appetite, energy levels, and concentration. To be diagnosed with major depression, an individual must experience at least five of these symptoms, including either depressed mood or loss of interest or pleasure. 
• Persistent Depressive Disorder (Dysthymia): A long-term form of depression with a depressed mood lasting for at least two years, along with other symptoms similar to those of MDD but often less severe. 
• Premenstrual Dysphoric Disorder: Severe mood swings, irritability, and physical symptoms that occur in the luteal phase of the menstrual cycle, markedly affecting daily functioning. 
• Perinatal Depression: Perinatal depression includes two types of depression related to having a baby. Prenatal depression happens during pregnancy and can make you feel sad or overwhelmed. Postpartum depression starts after the baby is born and can cause deep feelings of sadness, exhaustion, and difficulty in taking care of yourself and your baby. Men can also experience postpartum depression. 
• Seasonal Affective Disorder: Seasonal affective disorder (SAD) is a type of depression that occurs with the coming and going of the seasons. It usually starts in the fall or winter and lifts when spring or summer arrives. This condition is thought to be linked to changes in daylight and weather. 
• Depressive Disorder Due to Another Medical Condition: Depression that directly results from a medical condition such as chronic illness or neurological disorders. 

All these types share common features of sadness, emptiness, or irritability, significantly impacting an individual’s ability to function. Whether you’re struggling with severe, mild, or moderate depression, accurate diagnosis often involves assessing these symptoms and ruling out other causes through a comprehensive evaluation. 

How is depression diagnosed?

Diagnosing depression involves several key steps to ensure a thorough understanding of the condition. 

Here’s an overview of what typically happens: 

1. Clinical Assessment 

A mental health professional will begin by conducting a comprehensive assessment, which includes: 

• In-Depth Patient Interview: A detailed conversation where the clinician explores your current feelings, experiences, and their impact on your daily life. 
• Review of Personal and Medical History: Examination of your past and present medical and psychiatric history to identify any factors that might affect your mental health. 
• Mental Status Examination: An evaluation of your overall mental functioning, including how you perceive and interpret thoughts, emotions, and behaviors. This helps the clinician understand your cognitive processes and emotional responses and how these influence your daily activities. 
• Evaluation of Symptoms and Duration: Analysis of the nature, intensity, and duration of your symptoms to assess their impact on your daily functioning. 
• Assessment of Functional Impairment: Evaluation of how your symptoms affect your ability to carry out daily tasks and engage in regular activities. 
• Ruling Out Other Potential Causes: Determining whether your symptoms could be attributed to other medical conditions, medications, or substance use. 

2. Diagnostic Criteria 

Accurate diagnosis of depression involves a thorough psychiatric evaluation using the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This manual helps mental health professionals identify and categorize depression symptoms to guide effective treatment planning. 

Key Symptoms 

To diagnose Major Depressive Disorder (MDD), a person must exhibit at least five of the following symptoms during the same 2-week period, showing a change from previous functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure [1]. 

• Depressed Mood: Persistent sadness or hopelessness most of the day, nearly every day. For children and teens, this may also present as irritability. 
• Loss of Interest: Markedly reduced interest or pleasure in almost all activities most of the day, nearly every day. 
• Changes in Weight or Appetite: Significant weight loss or gain (more than 5% of body weight in a month) or notable changes in appetite. 
• Sleep Disturbances: Insomnia (difficulty sleeping) or hypersomnia (sleeping too much) nearly every day. 
• Psychomotor Changes: Observable agitation (e.g., restlessness) or retardation (e.g., slowed movements or speech). 
• Fatigue: Persistent fatigue or loss of energy nearly every day. 
• Feelings of Worthlessness or Guilt: Overwhelming feelings of worthlessness or inappropriate guilt nearly every day. 
• Difficulty Thinking or Concentrating: Impaired ability to think, concentrate, or make decisions nearly every day. 
• Recurrent Thoughts of Death: Thoughts about death or suicide, including specific plans or attempts. 
• Impact on Functioning: Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning [1]. 

3. Exclusion Criteria 

To ensure an accurate diagnosis, the clinician will confirm that none of the following factors could account for your symptoms [1]: 

• Substance or Medical Conditions: Symptoms should not be attributed to the effects of substances or other medical conditions. 
• Other Mental Disorders: The episode should not be better explained by other disorders such as bipolar disorder, schizophrenia, or schizoaffective disorder. 
• Manic or Hypomanic Episodes: There should never have been a manic or hypomanic episode. If such episodes occur, they must be substance-induced or due to another medical condition to be excluded from the diagnosis. 
• Differentiating from Grief: It’s important to distinguish MDD from normal grief, which typically involves feelings of emptiness and sadness linked to reminders of loss rather than a persistent depressed mood. 

Understanding these diagnostic steps can help clarify how depression is identified and addressed, ensuring a comprehensive approach to treatment [1]. 

Specifiers

Once a diagnosis of depression has been made, there are a few things that need to be taken into account in order to make a more specific diagnosis. These include the severity of the depression, how long the symptoms have been present, whether there is a seasonal pattern, and whether or not the person has had any previous episodes of depression.

• Severity: What is depression severity? The severity of depression can be mild, moderate, or severe. It is important to note that even mild cases of depression can be debilitating and cause a significant amount of distress.
• Duration: Acute cases of depression are those that last for less than 3 months. If the symptoms persist for longer than 3 months, it is considered to be a chronic form of depression.
• Recurrence: What is depression recurrence? If a person has had more than one episode of depression, it is considered to be recurrent. The interval between episodes can vary but must be at least 2 months in order for it to be considered recurrent.

When to Seek Help 

While everyone experiences emotional ups and downs, there are certain signs that indicate it might be time to seek professional help. If you notice any of the following symptoms persisting for two weeks or more, it’s advisable to consult a healthcare provider [5,11]: 

• Feeling sad, anxious, or “empty” most of the time 
• Losing interest in activities you used to enjoy 
• Significant changes in appetite or weight 
• Trouble sleeping or sleeping too much 
• Persistent fatigue or lack of energy 
• Difficulty concentrating or making decisions 
• Feelings of worthlessness or excessive guilt 
• Thoughts of death or suicide 

It’s especially important to seek help if your symptoms are: 

• Affecting your daily life and normal functioning 
• Causing problems in your relationships 
• Getting worse over time 
• Leading you to use alcohol or drugs to cope 
• Accompanied by thoughts of suicide [5,11] 

If you are experiencing thoughts of suicide or self-harm, seek emergency medical attention immediately. 

How is Depression Treated? 

Being diagnosed with clinical depression can be validating but also overwhelming. While it may provide clarity about your symptoms, it also means facing a serious mental health condition. Fortunately, there are several evidence-based depression treatment options to consider. 

Antidepressant medications like SSRIs can help regulate brain chemistry, though finding the right medication and dosage often takes time. Talk therapy can provide tools to reframe negative thought patterns and develop coping strategies. For those who don’t respond to first-line treatments, transcranial magnetic stimulation (TMS) offers a non-invasive option that uses magnetic fields to stimulate specific areas of the brain. Ultimately, developing an effective treatment plan is a collaborative process between patient and provider, often combining multiple approaches tailored to the individual’s needs. 

Medication 

Medications are often prescribed to help manage the symptoms of depression, especially when used in conjunction with therapy. 

Some of the main types of depression medication include [13]: 

• Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are commonly used to treat depression by increasing the levels of serotonin in the brain. This helps improve mood and reduce symptoms of depression. They are often preferred due to their relatively mild side effects compared to older antidepressants. 
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs work by boosting levels of both serotonin and norepinephrine, two neurotransmitters that affect mood. They can help alleviate depression and anxiety and are generally used when SSRIs are not effective. 
• Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs): NDRIs target the neurotransmitters norepinephrine and dopamine. By increasing the levels of these chemicals in the brain, NDRIs can help improve mood and concentration, making them useful for treating depression. 
• Esketamine: Esketamine is a newer treatment option for depression that has not responded to other antidepressants. Delivered as a nasal spray, it works rapidly to relieve symptoms. It is often used alongside traditional oral antidepressants for sustained effect. 
• Tricyclic Antidepressants (TCAs): TCAs are older medications that can be effective for depression but tend to have more side effects. They work by increasing levels of neurotransmitters in the brain but are less commonly used today due to the availability of newer options. 
• Monoamine Oxidase Inhibitors (MAOIs): MAOIs are another older class of antidepressants that help increase neurotransmitter levels by inhibiting the enzyme monoamine oxidase. They are typically used when other antidepressants are ineffective but require dietary restrictions to avoid severe interactions. 

The choice of medication and dosage is personalized, and it’s important to have regular follow-ups with a healthcare provider to monitor effectiveness and manage any side effects. 

Psychotherapy 

Several forms of psychotherapy have been shown to be effective for treating depression symptoms [3]: 

• Cognitive Behavioral Therapy (CBT): Cognitive Behavioral Therapy (CBT) focuses on identifying and changing negative thought patterns and behaviors that contribute to depression. By challenging unhelpful thoughts and developing healthier thinking habits, CBT helps individuals manage their symptoms more effectively. This therapy is typically short-term and goal-oriented, making it a practical option for many people. 
• Mindfulness-Based Cognitive Therapy (MBCT): Mindfulness-Based Cognitive Therapy (MBCT) combines elements of cognitive therapy with mindfulness practices. It helps individuals become more aware of their thoughts and feelings, recognizing them as temporary events rather than facts. MBCT often involves mindfulness exercises like meditation, usually conducted in a group setting for over eight weeks. It’s particularly helpful in preventing the recurrence of depression. 
• Interpersonal Therapy (IPT): Interpersonal Therapy (IPT) focuses on improving relationships and social functioning, which can be key factors in depression. IPT helps individuals explore how their interactions with others contribute to their depressive symptoms. The therapy typically centers on four main areas: grief, role transitions, role disputes, and interpersonal deficits. By addressing these areas, IPT aims to improve communication skills and resolve conflicts, leading to better emotional well-being. 
• Psychodynamic Therapy: Psychodynamic therapy delves into how unconscious thoughts and past experiences, especially from childhood, influence current emotions and behaviors. By bringing these issues to light, individuals can work through unresolved conflicts contributing to their depression. This therapy can be either short-term or long-term and often involves examining the relationship between the therapist and the patient as part of the healing process 
• Supportive Therapy: Supportive therapy provides a safe space for individuals to express their feelings and concerns. The therapist offers emotional support, helps the individual build on their strengths, and assists them in finding effective coping strategies. This type of therapy is especially beneficial for those who need help navigating difficult life situations while boosting their self-esteem and resilience [3]. 

Psychotherapy can be conducted individually, in groups, or with family members. It may be used alone for mild to moderate depression or in combination with medication for more severe cases.

Related: Depression Therapy: A Comprehensive Approach to Healing

Transcranial Magnetic Stimulation (TMS) Therapy 

Transcranial Magnetic Stimulation (TMS) is a non-invasive brain stimulation therapy that uses magnetic fields to influence brain activity. By placing a magnetic coil on the scalp, TMS targets specific areas of the brain related to mood and emotion, helping to regulate brain activity that might be disrupted in conditions such as depression and obsessive-compulsive disorder [7, 15]. This therapy is often considered for severe depression or when other treatments have not been effective. 

TMS does not require anesthesia and is generally painless, allowing most people to resume their daily activities immediately after a session [15]. The procedure has fewer side effects compared to other treatments; while mild and temporary side effects like headaches are possible, more severe effects such as seizures are rare [15]. TMS is particularly beneficial for individuals who have not responded to traditional treatments. Although it may take a few weeks to notice improvements, around 50% to 60% of patients who did not benefit from medications experience significant benefits from TMS [15]. 

Collaborating with Healthcare Providers 

Working closely with healthcare providers is essential for determining the most effective treatment for depression. Providers use your diagnosis and personal history to create a tailored treatment plan, adjusting it as needed based on your response. This collaborative approach ensures that all aspects of your health are considered, helps manage potential side effects, and supports informed decision-making about your therapy options. Regular communication with your provider maximizes the chances of successful treatment and overall well-being. 

Depression Treatment Designed for You  

If you or someone you know is struggling with depression, Neuro Wellness Spa is here to help. Reach out to us today to explore tailored treatment options. Our team of highly trained and compassionate mental health professionals offers a variety of treatments, including in-person and online psychiatry for medication management, in-person and virtual psychotherapy utilizing effective depression therapies, and TMS therapy which stimulates parts of the brain that are responsible for mood regulation. We are dedicated to creating personalized treatment plans to meet your unique needs and support your journey to wellness.

References 

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. 
2. American Psychiatric Association. What is depression? https://www.psychiatry.org/patients-families/depression/what-is-depression 
3. American Psychological Association. Depression treatments for adults. https://www.apa.org/depression-guideline/adults/ 
4. Avasthi, A., & Ghosh, A. (2014). Depression in primary care: Challenges and controversies. The Indian Journal of Medical Research, 139(2), 188–190. 
5. Centers for Disease Control and Prevention. Mental health conditions: Depression and anxiety. https://www.cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html 
6. Chand, S. P., & Arif, H. (2023, July 17). Depression. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430847/ 
7. Cleveland Clinic. Transcranial magnetic stimulation (TMS). https://my.clevelandclinic.org/health/treatments/17827-transcranial-magnetic-stimulation-tms 
8. Docherty, J. P. (1997). Barriers to the diagnosis of depression in primary care. The Journal of Clinical Psychiatry, 58(Suppl 1), 5–10. 
9. Lee, M. S., & Passarotti, A. M. (2022). Editorial: Addressing the challenges in the diagnosis of depressive disorder in children and adolescents. Frontiers in Psychiatry, 13, 1011301. https://doi.org/10.3389/fpsyt.2022.1011301 
10. Liu, X., & Jiang, K. (2016). Why is diagnosing MDD challenging? Shanghai Archives of Psychiatry, 28(6), 343–345. https://doi.org/10.11919/j.issn.1002-0829.216073 
11. Mayo Clinic. Depression (major depressive disorder). https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007 
12. National Institute of Mental Health. Depression. https://www.nimh.nih.gov/health/publications/depression 
13. National Institute of Mental Health. Mental health medications. https://www.nimh.nih.gov/health/topics/mental-health-medications 
14. Park, S. C., & Kim, Y. K. (2021). Challenges and strategies for current classifications of depressive disorders: Proposal for future diagnostic standards. Advances in Experimental Medicine and Biology, 1305, 103–116. https://doi.org/10.1007/978-981-33-6044-0_7 
15. Stern, A. (2020, October 27). Transcranial magnetic stimulation (TMS): Hope for stubborn depression. Harvard Health. https://www.health.harvard.edu/blog/transcranial-magnetic-stimulation-for-depression-2018022313335