In their recent book “The Loss of Sadness” (Oxford, 2007), Allan V. Horwitz and Jerome C. Wakefield assert that for thousands of years, symptoms of sadness that were “with cause” were separated from those that were “without cause.” Only the latter were viewed as mental disorders.
With the advent of modern diagnostic criteria, these authors argue, doctors were directed to ignore the context of the patient’s complaints and focus only on symptoms — poor appetite, insomnia, low energy, hopelessness and so on. The current criteria for major depression, they say, largely fail to distinguish between “abnormal” reactions caused by “internal dysfunction” and “normal sadness” brought on by external circumstances. And they blame vested interests — doctors, researchers, pharmaceutical companies — for fostering this bloated concept of depression.
But while this increasingly popular thesis contains a kernel of truth, it conceals a bushel basket of conceptual and scientific problems.
For one thing, if modern diagnostic criteria were converting mere sadness into clinical depression, we would expect the number of new cases of depression to be skyrocketing compared with rates in a period like the 1950s to the 1970s. But several new studies in the United States and Canada find that the incidence of serious depression has held relatively steady in recent decades.
Second, it may seem easy to determine that someone with depressive complaints is reacting to a loss that touched off the depression. Experienced clinicians know this is rarely the case.
Third, and perhaps most troubling, is the implication that a recent major loss makes it more likely that the person’s depressive symptoms will follow a benign and limited course, and therefore do not need medical treatment. This has never been demonstrated, to my knowledge, in any well-designed studies. And what has been demonstrated, in a study by Dr. Sidney Zisook, is that antidepressants may help patients with major depressive symptoms occurring just after the death of a loved one.
Tuesday, October 21, 2008
Redefining Depression as Mere Sadness
An article by Pies with the title of this post is worth reading. It deals with the criticism that modern psychiatric practice, in collusion with pill pushing pharmaceutical companies, has medicalized “normal sadness” brought on by external circumstances. (Added note: Pies has emailed this this link to a more detailed discussion posted on the PsychCentral website.) Here are some clips from the NYTimes article: