We’ll all be depressed?

I was having a conversation about depression recently. I heard that not much has changed in the new ICD11 criteria. I checked and think the changes are breathtaking.  It’s easier to be diagnosed with depression. No, it’s much easier. The brand spanking new ICD11 has removed all restrictions.

Here are the two accounts of depression. The ICD10 stipulates the following criteria:

  1. Depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstance, and sustained for at least 2 weeks.
  2. loss of interest or pleasure in activities that are normally pleasurable
  3. decreased energy or increased fatiguability.

Six further diagnostic criteria are listed:

  • loss of confidence and self-esteem;
  • unreasonable feelings of self-reproach or excessive and inappropriate guilt;
  • recurrent thoughts of death or suicide, or any suicidal behaviour;
  • complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation;
  • change in psychomotor activity, with agitation or retardation (either subjective or objective);
  • sleep disturbance of any type.

The ICD11 (the link is here), on the other hand, has this:

A depressive episode is characterised by a period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least two weeks accompanied by other symptoms such as

    • difficulty concentrating,
    • feelings of worthlessness or excessive or inappropriate guilt,
    • hopelessness,
    • recurrent thoughts of death or suicide,
    • changes in appetite or sleep,
    • psychomotor agitation or retardation,
    • reduced energy or fatigue.

 

So, let’s have a look at what’s changed. I am not going to comment on deletions, movement or introduction of new criteria. I am only interested in how they are rendered. And just on that score, the ICD11 criteria have been extended significantly. First, it’s the depressed mood. ICD10 asks for:

Depressed mood to a degree that is definitely abnormal for the individual

Can you see the modifying clause ‘definitely abnormal’? It’s what linguists call a hedge, it modifies the range of the phrase it is attached to. The ICD11 removes it. Now you only have to

have depressed mood.

It’s worth saying that the ‘definitely abnormal’ phrase is to semantically empty, really. Abnormality is notoriously difficult to assess, the adverb ‘definitely’ is as fuzzy. And so, it’s hard to know what exactly the authors of the ICD10 had in mind. But the phrase has another important function – it urges the clinician to make sure that the depressed mood is something out of the ordinary. It doesn’t tell the clinician how to do it, but serves as a caution not to jump to conclusion. By removing it, the clinicians are no longer warned to take care.

The second extension is here. The ICD10 says:

loss of interest or pleasure in activities that are normally pleasurable

The 11th edition replaces it with:

diminished interest in activities occurring most of the day

So, before you had to lose your interest, now you just need (a bit) less of it. Before, you had to lose your interest in things that are ‘normally pleasurable’, now it’s only in the daily stuff. Isn’t it  harder to lose interest in things that are fun, than have less interest in things that are ordinary? I think it is.

There is another disappearance from the ICD11. The earlier stipulation that the depressed mood must be

largely uninfluenced by circumstance,

has disappeared. The ICD11 seems generally about removing qualifications. For example,

unreasonable feelings of self-reproach or excessive and inappropriate guilt;

become:

feelings of worthlessness or excessive or inappropriate guilt

In the ICD11 such feelings need not to be unreasonable anymore, nor do they need to be excessive.

But note this change. The phrase:

complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation;

has been changed to

difficulty concentrating

That’s quite a change, isn’t it? What had to be based on an explicitly mentioned complaint or evidence, becomes just a symptom like all others. ‘Diminished ability’ becomes ‘difficulty’, while examples such as indecisiveness or vacillation disappear altogether.

There are other things. I find it interesting that ‘fatigability’ becomes ‘fatigue’ and the change from ability to condition doesn’t seem very clear. Still, the ICD10 understands that fatigability must change, while ICD11 doesn’t require any change here, though, somewhat surprisingly, does requite change in the levels of energy. Psychomotor activity doesn’t need to change either.

And so, depression has changed, and it has changed significantly. It will be considerably easier to get a diagnosis of depression. With this, presumably, it will be easier to be put on medication.

But one thing doesn’t change. As the ICD11 extends depression, the linguistic form in which the symptoms are rendered remains as it has been. Invariably put as nouns, symptoms are rendered as things. Such complex, dilemmatic, extended-in-time processes as losing one’s confidence or thinking about killing oneself are rendered as obvious, clear, unproblematic objects to be spotted by the clinician. The symptoms are rendered as objective, almost universal, as if the suicide thoughts of one person were exactly of the same nature as those of another. The clinician/researcher is supposed to simply observe the symptoms and count them, from four to eight – depending on the severity of the episode.

In all this, there is no patient, no experience of illness, no distress. All that which happens with the person who comes for psychiatric help is reduced to a few ‘objective’ categories which the diagnostician can easily assess. There is no context, no individuality. The ICD continues to construct a version of psychiatry in which a patient is a set of symptoms which are to be harvested by the shrink. S/he is a transparent conduit of symptoms which are to be treated, as if these symptoms simply existed ‘out there’ or in the patient, for all suitably trained to see. I also continue to think that such removal of complexity of experience of distress is a sign psychiatry’s powerlessness.

I am sorry to say that the ICD continues to ignore the very core of psychiatric practice – the individual clinical encounter.

 

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