Jonah Lehrer, the editor of Mind Matters, asked Allan Horwitz, professor of sociology at Rutgers University, and Jerome Wakefield, professor of social work at New York University, a few questions about their recent book, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Illness.
LEHRER: In your book, you take a critical look at major depressive disorder (MDD), a mental illness that will afflict approximately 10 percent of individuals at some point during their life. In recent decades, the number of cases of MDD has sharply increased. Are we currently experiencing an epidemic of depression? Or is this surge due to changes in diagnosis?
HORWITZ AND WAKEFIELD: Our book argues that, despite widespread beliefs to the contrary, the rate of depressive disorders in the population has not undergone a general upsurge. In fact, careful studies that use the same criterion for diagnosis over time reveal no change in the prevalence of depression. What has changed is the growing number of people who seek treatment for this condition, the increase in prescriptions for antidepressant medications, the number of articles about depression in the media and scientific literature, and the growing presence of depression as a phenomenon in popular culture. It is also true that epidemiological studies of the general population appear to reveal immense amounts of untreated depression. All of these changes lead to the perception that the disorder itself has become more common.
In fact, we think what has really changed is that since 1980 psychiatry and the other mental health professions have used a definition of depression that conflates genuine depressive disorder with intense, but normal, states of sadness. Since the third version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III) was published in 1980 psychiatry has relied primarily on a list of symptoms for its definition of depressive disorder. So someone who has five symptoms out of a list that includes things like depressed mood, loss of interest in usual activities, insomnia, fatigue, lessened appetite, an inability to concentrate and similar symptoms for as brief a period as two weeks is considered to have a depressive disorder.
Yet loss events such as a betrayal by a romantic partner, being passed over for a much-anticipated promotion, failing an important test, having a mortgage foreclosed, or discovering a serious illness in oneself or a loved one could naturally lead the same symptoms to arise and endure for a two-week period. When such criteria are applied to the general population, very large estimates of untreated depressive disorder emerge, because one is capturing intense normal reactions to losses as well as genuine depressive disorder.
Before 1980, for the 2,500 years since the dawn of psychiatric medicine, only symptoms that were “excessive” and inexplicable relative to their provoking context were considered to be signs of a depressive disorder. After 1980 all symptoms, even those that are proportionate to their provoking cause, were defined as disordered. This change means that intense natural reactions to loss events as well as disordered responses have been seen as mental disorders, thus accounting for the apparent increase in depression in recent years.
LEHRER: What has led to these changes in diagnosis?
HORWITZ AND WAKEFIELD: Initially, the changes in the diagnosis of depression resulted from efforts by research scientists, in response to widespread critiques of the unreliability and unscientific nature of psychiatric diagnosis, to make the criteria for depression (and other mental disorders) more easily measurable, precise and reliable so that different mental health professionals would make the same diagnosis when they saw patients with similar symptoms.
Once depression came to be defined by its symptoms, however, the definition of the mental illness took on a life of its own. Mental health advocates, for instance, liked the fact that it produced high estimates of the amount of depressive mental disorder so that it seemed as if depression was a “public health problem” of massive proportions. Clinicians could get reimbursed for conditions that might actually be non-medical problems. Perhaps most important, pharmaceutical companies found that they could portray people who suffered from widespread psychosocial problems in their advertisements while at the same time marketing their products as treatments for depressive mental disorders. And, of course, many individuals find it more acceptable to frame their problems as the result of a mental disorder and to take psychotropic drugs to attempt to relieve their distress than to see their suffering as the result of psychosocial problems. So, although the internal dynamics of the psychiatric profession initially led to the changes in the diagnostic criteria, once the criteria arose they have been perpetuated by a variety of groups that benefit from them.
LEHRER: What are some of the benefits and costs associated with the phenomenon you refer to as the "medicalization of sadness"?
HORWITZ AND WAKEFIELD: We recognize that the symptom-based definition of depression has had some beneficial effects, such as the growing number of people who receive mental health treatment, the decline in the stigma associated with this condition and the flourishing of scientific research about depression. We also think, however, that the medicalization of sadness has a number of costs. One is that calling a condition a “depressive disorder” prejudges the nature of that condition and suggests that medication is the most appropriate response to it. General physicians, as well as psychiatrists, seem almost reflexively to prescribe drugs for many conditions that might actually reflect normal, intense sadness and are likely self-limiting. Another is that defining sadness as depression can tend to close off non-medical interventions including various sorts of social support, psychotherapies, changes in life circumstances or turning the sufferer’s attention to confronting their psychosocial situation—and can undermine resolve to address social problems that make people miserable by reframing that misery as a widespread individual medical disorder.
Some other costs involve the research implications of confusing natural sadness and depressive disorder. Scientists are likely to see these conditions as homogeneous whereas, in fact, they have different etiologies and prognoses. Policy makers, for instance, might be tempted to see high rates of depression as signs that mental health treatment instead of social change is warranted. So, there are many possible costs to the medicalization of sadness because it misleads our thinking in every area, from policy and research to clinical intervention and our own personal understandings.
LEHRER: How can psychiatrists learn to distinguish between "intense sadness," which can often constitute a normal emotional response to loss, and MDD?
Although the distinction between normal intense sadness and depressive disorder is often subtle, there are some differences that can be used to separate these conditions. One is that intense sadness should be sensitive to social context. It not only arises but also persists as a function of a situation of loss. This fact means that if the situation improves—a person who is dumped by a romantic partner finds a new partner or someone who loses a job finds another—the sadness should dissipate. In contrast, depression is relatively impervious to such positive changes. People themselves sometimes can tell the difference—they report that what they are feeling does not feel like being intensely sad when grieving but is qualitatively different in its sense of numbness and immobility. A further difference is that normal sadness is typically of relatively shorter duration, unless the stress is chronic or itself recurs; over time people naturally tend to adjust to situations of loss and there is a spontaneous trajectory of recovery as people reconstruct their lives after the loss. In contrast, depressive disorders are more enduring. Finally, some especially serious symptoms such as hallucinations, delusions and vegetative symptoms in themselves suggest the presence of a disordered condition.
LEHRER: If, as you argue, antidepressants aren't always the answer, then how should people deal with intense sadness?
HORWITZ AND WAKEFIELD: There is no single response that fits all cases of intense sadness, but different people will find various alternatives to be most suitable for their own cases. “Watchful waiting” is often the most desirable alternative to see if the condition improves on its own as the person adjusts to the loss. And there are also many things one can do.
First, we are very fortunate that there are a variety of psychotherapies that research indicates are as effective as medication in treating depression—perhaps with the exception of the most severe cases. These approaches include, for example: cognitive-behavioral therapy which looks at how an individual’s negative thinking is biasing their interpretation of environmental events and influencing mood; interpersonal therapy, which has the individual work intensively on addressing the most important relationship issues that are a source of depression; and behavioral activation, which has the individual systematically act to change the circumstances that are causing sadness. As you can see, these therapies are based on principles that individuals might apply to themselves even without the help of a therapist, and all involve acting to change one’s relationship to the environmental factors that are causing the distress.
Therapy aside, sadness is a complex emotional/cognitive state that indicates that something has gone wrong with some of the aspects of life the individual most cares about. So one response is to take it seriously and think hard about how one’s life is not going well and what one might do to change it. Seeking social support and altering one’s social and exercise routines can often help. Some might find antidepressants will bring relief for their suffering, even when they don’t have a disorder. This decision, however, should be made under conditions of full knowledge that, despite the intensity of their suffering, it is likely to improve in the future without the aid of a drug.
What we hope people and their physicians don’t do is make the simple assumption that the presence of a particular group of symptoms for a short period of time always indicates the presence of a depressive disorder. Negative emotions such as sadness are a natural part of life and, although there is nothing wrong with wanting to feel better, they should not automatically be treated as signs of a disease.