The ways in which depression is currently understood derive from criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (APA, 2013) and the International Classification of Diseases (ICD-11). Decisions about the presence of a ‘disorder’ is primarily based on the presence of symptoms, their duration and disturbance of functioning.

However, debates continue over whether depression even differs from sadness, whether by diagnosing it we are ‘medicalising unhappiness’, and how ‘distress’ can, or should, be distinguished from ‘depression’ (Bentall & Pilgrim, 1999; Dowrick, 2009; Dowrick & Frances, 2013; Horwitz & Wakefield, 2007).

DSM-5 highlights the need for “…the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss”. This can be difficult, and GPs’ views vary; with ideas about depression that range from considering it essentially as a social process and a normal response to life events, to more of a biomedical disorder (Barley et al, 2011).

Identifying ‘depression’ in primary care can be complex, and, as the authors of this paper rightly conclude, is often glossed over in favour of simply focussing on improving its management.

So, the aim of this study was to explore how general practitioners (GPs) distinguish between emotional distress and depressive disorder.

Methods

A qualitative interview study was conducted to explore how GPs distinguish emotional distress and depression. The data were collected through face-to-face and telephone interviews with GPs from the South of England (N=21), who were working in UK primary care practices (N=19).

• Targeted practices had differing list sizes, deprivation indices and urban/rural locations
• GPs were purposively sampled to provide diversity across gender, age and years since qualification.

Interviews followed a semi-structured interview guide focusing on ideas about emotional distress (ED) and depressive disorder (DD) in primary care patients. The participants were asked to:

• Describe a patient they had seen who was experiencing a DD or ‘clinical depression’ and a patient who presented with ED (who they did not believe was depressed). Then they were asked to describe the differences between the two
• Discuss factors that would affect treatment, diagnostic labelling and their thoughts on suggested definitions of distress and disorder.

Interviews were carried out by one of the authors who was a (closely supervised) medical student at the time and recorded.

The thematic analysis followed the model proposed by Braun & Clarke (2006), while a team of diverse expertise (including a psychologist and academic GPs) collaborated to develop and finalise a coding frame, develop themes and discuss interpretations.

Public and patient involvement was at the level of the overall research programme only. GP colleagues contributed to the information sheet and interview schedule.

Results

Participant characteristics

The median age was 45 years (range 38-58). Twelve of the GPs were male and 9 female with a median of 16 years practicing as a GP (range 7 to 30), median 9,998 list size of practice (3,400 to 17,829), median deprivation index 14.1 (6 to 28.1), and a split between 11 urban and 10 rural.

Although data are provided on how the participants conceptualised depression/emotional distress, and the GP role in management, for reasons of brevity I will focus here on the key research question: distinguishing one from the other.

Views, unsurprisingly, were divergent.

Some GPs suggested a distinction was not possible as symptoms lay on a continuum, with severity as a proxy for disorder. Others found this less useful and looked to other factors such as duration and the potential of distress to fluctuate to a greater degree than depressive disorder. Some found severity scales such as the PHQ-9 (Kroenke, 2001) unhelpful.

Others focused on the difficulty of the distinction and were uncertain, with less formed ideas about the complexities of distress versus disorder.

I mean what is depression? Okay, if you look at the guidelines for what depression is, that’s normally something acute that happens in your life but it’s not really depression whereas, you know—I don’t know would call what I call true depression—I mean—it’s very difficult to define in this sort of way. Okay, it can have different presentations.

Some GPs perceived a distinction and referred to emotional distress as more likely in the presence of a stressor with the absence of biological symptoms. It was also common for GPs to refer to reactive and endogenous depression when considering possible distinctions between emotional distress (ED) and depressive disorder (DD) but using the terms in a different way from psychiatry where both are considered to be types of depression. Here- ‘reactive’ was taken to mean ‘distress’.

Within the complexity of the issues described, some referred to transitions from ED to DD in the context of complicated bereavement and chronic stress and appeared to be drawing on a process narrative rather than identifying symptoms and classifying them. Duration was often viewed a key factor in detecting ‘disorder’.

Conclusions

The authors concluded that:

GPs’ perceptions of when emotional symptoms reflect disorder varied greatly, with a broad range of views presented.

And

Further research is needed to develop more consistent frameworks for understanding emotional symptoms in primary care.

Strengths and limitations

The authors stated the strengths of their research including that:

• this is a novel study, because it asked doctors how they distinguished between depression and distress, rather than simply studying ‘how well they detect depression’.
• the study included a well-balanced sample of GPs (in terms of gender, years practicing, age, practice size, deprivation in practice area).

I would add that this is an excellent example of integrating a supervised student researcher in a well-designed qualitative multidisciplinary project; something which many students would benefit from.

However, they acknowledge that some limitations exist:

• GPs were from a relatively small geographical area in the South of England (this would have been much improved if they had been sampled from a national database of practices).
• The patients these GPs see may be relatively homogenous. GPs who work with more diverse populations may have different perspectives on depression and distress. In my opinion this is a crucial limitation, as cultural and religious factors can play a key part in how depression and distress are perceived.
• The interview topic guide was developed with GPs, but direct patient and public involvement may have further contributed to the topics covered in the interviews.

I would add to these limitations already mentioned by the authors that:

• The study doesn’t mention the further level of complexity; that mixed anxiety and depression is the most common presentation in primary care.
• The authors also provide no information about the extent of the GPs previous training or experience in psychiatry, both pre and postgraduate, which might help to understand how their views developed and diverged.

Implications for practice

The approach to conceptualising ‘depression’ recommended by DSM5 and ICD11, focusing on symptom counts and severity, increases the reliability of diagnosis. However, symptoms may be driven by many different processes, only some of which indicate the presence of underlying disorder, so this ‘simple’ approach may actually increase complexity for GPs faced with what Michael Balint (the psychoanalyst) called ‘undifferentiated’ symptoms in primary care (Gask, 2008).

Confusion about ‘depression’, reflected here, is understandable. I was first taught about ‘endogenous’ and ‘reactive’ as well as ‘psychotic’ and ‘neurotic’ depression, only to be introduced later to the idea of a single ‘depression’ with varying severity. Personally, I think there are many different experiences of ‘depression’ which all vary according to the part played by social context, psychological and biological factors in their aetiology and presentation. What used to be called ‘melancholia’ or ‘endogenous’ depression can simply arrive ‘out of the blue,’ but life events play a key role in triggering depression in the presence of underlying vulnerabilities (genetics, early experience, physical health, social stresses) (Goldberg & Goodyer, 2005) and their presence shouldn’t lead to an assumption that this is merely ‘distress’.

We should move beyond simplistic explanations and talk more about the dynamic processes by which ‘distress’ and ‘depression’ are interconnected.

Statement of interests

Linda Gask has a lifetime of treating, teaching about and researching depression, alongside GPs, as well as experiencing it herself.

Links

Primary paper

Geraghty AWA, Santer M, Beavis C, et al. (2019) ‘I mean what is depression?’ A qualitative exploration of UK general practitioners’ perceptions of distinctions between emotional distress and depressive disorder. BMJ Open 2019;9:e032644. doi:10.1136/bmjopen-2019-032644

Other references

American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, fifth edition. DSM-5. Arlington, VA: American Psychiatric Publishing, 2013.

Barley EA, Murray J, Walters P, et al. (2011) Managing depression in primary care: a meta-synthesis of qualitative and quantitative researchvfrom the UK to identify barriers and facilitators. BMC Family Practice 2011;12:47.

Bentall R, Pilgrim D (1999) The medicalisation of misery: A critical realist analysis of the concept of depression. Journal of Mental Health 1999 8.3: 261-274.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3:77–101.

Dowrick C. (2009) Beyond depression: a new approach to understanding and management. Oxford University Press, 2009.

Dowrick C, Frances A. (2013) Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit. BMJ 2013;347:f7140.

Gask L, Klinkman M, Fortes S, et al. (2008) Capturing complexity: the case for a new classification system for mental disorders in primary care. European Psychiatry. 2008;23(7):469-76.

Goldberg DP, Goodyer IM. (2005) The origins and course of common mental disorders. Taylor & Francis; 2005.

Horwitz AV, Wakefield JC. (2007) The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. New York: Oxford University Press, 2007.

Kroenke K, Spitzer RL, Williams JB. (2001) The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 2001; 16:606–13.

Photo credits

• Photo by Jorge Salvador on Unsplash
• Photo by Andrik Langfield on Unsplash
• Photo by Mansur Omar on Unsplash
• Photo by tribesh kayastha on Unsplash
• Photo by Drew Beamer on Unsplash