Difficulties in assessing depressive-like reactions to chronic severe external stress as exemplified by spouse caregivers of Alzheimer patients

Problems in making differential diagnoses and severity ratings of depressive-like reactions in chronically, heavily stressed persons are described. These assessment concerns are especially pertinent to older persons. The assessment concern discussed relates to difficulties in determining the extent to which stress reactions are inevitable consequences of stressor demands versus excessive pathological reactions versus natural manifestations of aging. The newly revised criteria of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III-R) and its associated structured interviews do not lessen the difficulties described. However, they reflect progress in specifying the amount of cross-sectional and longitudinal consistency required before maladaptive behaviours meet diagnostic and/or severity criteria as pathological indicators. Stressor level is important among the criteria for the less severe DSM-III-R depression-related disorders, but the specific response demands of the stressors are ignored. By contrast, biomedical factors are consistently given significant weight. To clarify these matters, the five DSM-III-R diagnostic axes, depressive diagnostic criteria, and associated structured interviews for eliciting relevant data are reviewed.