Why Diagnosis Remains Psychiatry's Hardest Task in MDD

Welcome back to another Psychiatric Times Peers & Perspectives series. In "Why Diagnosis Remains Psychiatry's Hardest Task in MDD," moderator Leslie Citrome, MD, MPH is joined by Lisa Harding, MD to open the series on major depressive disorder, beginning with the symptoms that bring patients through the door.

Dr. Harding opens by explaining that diagnosis, not treatment, is the hardest part of psychiatry. She contrasts her earlier career as an emergency room physician, where symptoms map quickly to a diagnosis and a fix, with psychiatry, where clinicians take reported words, map them to a syndrome, and infer the brain circuitry involved. She notes psychiatry lacks the objective testing available in other specialties, so history-taking carries far more diagnostic weight than it does elsewhere in medicine.

Dr. Harding identifies low mood and anhedonia as the cardinal symptoms that typically bring a patient in for evaluation. She distinguishes these from the neurovegetative symptoms of depression, such as fatigue, appetite change, and poor concentration, which are often caught first in primary care and initially attributed to a medical cause. She adds that over the past five to ten years, clinicians have grown more willing to recognize overlapping diagnoses rather than settling on one explanation too quickly, changing how depression eventually gets identified and named.

Dr. Citrome describes patients who are brought in by concerned family members who notice a loved one no longer seems like themselves or has lost interest in activities they once enjoyed. He cautions that patients without that kind of support system at home may go unnoticed and untreated for far longer, since no one prompts them to seek care in the first place. He notes that patients often cannot articulate what is wrong on their own, so clinicians must proactively ask about symptoms rather than waiting for patients to volunteer them unprompted.

Dr. Citrome also raises the importance of considering bipolar depression in the differential diagnosis, particularly in younger patients, because the appropriate treatment approach diverges sharply from unipolar major depressive disorder, making the distinction clinically consequential from the very first visit.

The next episode in this series, "What Brings Patients In: Functional Symptoms and Remission as the Goal," features Erin Crown, MHS, PA-C, CAQ-Psychiatry on the symptoms that drive patients into care and why remission remains her treatment target.