Just curious to hear other peoples accounts. When patient's come in looking to be started on antidepressant meds because they, for example lost their jobs and feel "down," or they are having marital problems and feel "stressed." Do they usually feel relieved or do they feel increased anxiety at the fact that you are not recommending meds for them?
Along the same lines, how do you guys discuss with patient's the difference between crappy life situations and the actual disease MDD.
What is the "the actual disease MDD"? depression is not a disease but an extremely heterogenous and pathoplastic syndrome, and what we call major depressive disorder is typically caused by life events related to loss, failure or humiliation, on the background of childhood adversity, and perpetuated by lack of social support. genetic and individual differences is stress reactivity, response to maternal nurturance, and threat appraisal also play their role. You would also be hard pressed to find a depressed person who didn't have marital problems if for no other reason than being depressed tends to adversely affect interpersonal relationships - and that is likely to worsen or perpetuate depression. In fact, couples therapy is an under-utilized and effective treatment for depressive illness, recommended in the UK NICE Guidelines for depression.
Although I do believe there is a difference between endemic misery due to **** life syndrome and a different kind of depressive despair, the distinction is a blurry one. In the past there was the concept of reactive depression and endogenous depression (also called neurotic depression and psychotic depression respectively). The idea was that some depression were reactions to loss events and may respond better to psychotherapy, and some depressions came out of the blue, presumed to be biological in nature, and may respond better to drugs. Although this sort of dichotomous thinking still persists in the field, it has long been debunked. Gene Paykel and Gerald Klerman studied this is in the 1960s and 70s and found that patients with "reactive depressions" responded just as well to antidepressants as patients with endogenous depressions, and with careful history taking, life events preceding the onset of depression could be identified even in those with so-called endogenous depressions. Behavior activation and even cognitive-behavior therapy have been shown to be effective even in patients with severe depression used alone without drugs. The Australian Psychiatry Gordon Parker still argues that there is a difference between neurotic and more biological depression and that there are different treatment approaches - for example antidepressants would be more effective in trials if we were better able to select those with the more "biological depressions". (Neurotic depressives on the other hand may respond to chocolate). Jerome Wakefield has argued that DSM-IV's bereavement exclusion should be expanded to include all other loss events so that you cannot diagnose major depressive disorder if there was a loss event (he argues this would prevent the medicalization of normal suffering). The historian Edward Shorter has argued we should bring back the concept of "nerves" for more milder reactive depressive states, to distinguish it from "melancholia" a more biological form of depression. These are appealing but not terribly convincing arguments however.
The difference is not really between severe and less severe, reactive and endogenous, psychosocial and biological however - the real difference in depression is single vs. recurrent. 50% of patients who have a major depressive episode will never have another episode. These patients appear quite distinct from the 50% who have 2 or more episodes (most of these having several). Patients with a single episode tend to experience depression later in life, and in response to a more severe life event. This has led to the idea there was something more inherent (genetic) about recurrent depressives. Also patients with recurrent depression are more likely to have a family history of bipolar disorder (incidentally manic-depressive illness diagnosis included both recurrrent unipolar depression as well as today's bipolar disorder). So there is likely some element of heritability at play that provides vulnerability in how we respond to childhood environments. However the real difference between recurrent and single depressive episodes is childhood adversity. Patients who experience neglect in childhood are more likely to be sensitized to react to more minor life events in adulthood by becoming depressed. The idea is that neglect leads to more hyperreactivity of the HPA axis to stressors. Constance Hammen has shown that women with recurrent depression do not experience more fateful life events than non-depressed women (i.e. acts of god like floods, people dying ) but they experience more dependent life events (i.e. life events that they are active participants in - such as job loss, marital breakup etc). Depressives thus contribute to creating the life events that make them depressed. Part of this has been attributed to having a negative cognitive style.
For example if you tend to think "I'm going to fail this exam" you might not study very hard for it, then you fail (self-fulfilling prophecy), and then tell yourself "see, I am a failure, just like my dad said" (confirmation bias) and then become depressed etc.
To answer your antidepressant question: this is something PCPs deal with much much more so than psychiatrists as usually there has to be something more wrong with you to go and see a psychiatrist in the first place (failed treatments, personality disorder, comorbid illnesses etc). But the placebo effects in patients who don't have major depressive illness are pretty good so these patients often do appear to respond to antidepressants, partly from placebo effect, partly because an antidepressant prescription is like throwing a lifeline to a drowning person out at see, and may also act a "gift" from the doctor to let the patient know she is loved, or as a transitional object that provides a level of comfort to the patient who cannot self-sooth or lacks a close confiding relationship.
