Clinical:An Epidemic of Depression

Major depressive disorder (MDD) has become psychiatry’s signature diagnosis. Depression is diagnosed in about 40% of patients who see a psychiatrist. This percentage is double that of just 20 years ago, and it is far higher than that of any other diagnosis. The World Health Organization (WHO) estimates that worldwide depression is the leading cause of disability for people in midlife and for women of all ages.

Antidepressants

Consumption of antidepressants has soared since 1990. Roughly 10% of women and 4% of men in the United States take antidepressant medication at any time. By 2000, antidepressants were the best-selling prescription drugs of any type. Yet epidemiological studies suggest that there are still vast numbers of untreated depressed individuals. Consequently, primary care practitioners have been recruited as the first line of defense, and many now routinely screen patients for depression. To catch the problem early, a presidential commission has recommended that every adolescent in the country should be screened for depression by the time he or she reaches age 18. Screening is proceeding in some schools.

Epidemic of Depression

What accounts for this seeming epidemic of depression? Although depression has been part of the psychiatric canon since the earliest writing of the ancient Greeks, depression was a relatively insignificant diagnosis just 50 years ago. In our recent book, The Loss of Sadness: How Psychiatry Transformed Normal Misery Into Depressive Disorder (Oxford University Press), we argue that the recent pandemic of seeming depressive disorder is the result of changes in the psychiatric diagnostic system presented in DSM-III in 1980 and that persist to the present.

In many respects, DSM-III (and subsequent versions) has been one of psychiatry’s greatest accomplishments. It was the first to use observable symptoms, rather than unobservable (and undemonstrated) etiological processes, to define the various types of mental disorders. Its clear definitions of discrete categories of disorder enhanced diagnostic reliability, thus putting to rest antipsychiatric arguments about the spuriousness of psychiatric diagnosis. These definitions allowed psychiatrists to communicate in a common theory-neutral language, irrespective of theoretical perspectives, that improved the cumulativeness of research.

Yet, these undoubted achievements also entailed some important disadvantages. These drawbacks have become especially apparent in the definition of MDD, and have had substantial social consequences.

Diagnosis and Diagnosis Problems

A diagnosis of MDD is warranted, according to DSM, when a patient has at least 5 of 9 specified symptoms for at least 2 weeks, and the 5 symptoms include either depressed mood or an inability to derive pleasure from life. The sole exception is that bereaved patients are not considered to have a disorder if they otherwise meet the criteria, as long as their symptoms are not unusually severe and last no longer than 2 months. The reason for the bereavement exclusion seems obvious: people who respond to the loss of an intimate with intense sadness, sleep and appetite difficulties, a loss of concentration on usual roles, and the like, do not have a mental disorder. Rather, they are responding normally to a situation of intense loss. The distinction between sadness that is a normal result of painful losses and depressive disorder is a fundamental one that has been explicitly recognized throughout the 2500-year history of psychiatric medicine.

Yet, the bereavement exclusion raises the question of whether people with enough symptoms to meet the MDD criteria—after, for example, the unexpected loss of a valued job, the collapse of a marriage, the failure to achieve a highly valued goal, or the diagnosis of a life-threatening illness in oneself or a loved one—are similarly reacting normally to situations of intense loss. For thousands of years, until DSM-III, physicians understood that these kinds of situational contexts were an important consideration in determining whether someone was experiencing normal—although intensely distressing—sadness or a depressive disorder in which something has gone wrong with mood processes and the sadness symptoms are no longer linked to the situation or likely to remit over time. Unlike many other diagnoses in DSM, which contain qualifiers that require symptoms to be “excessive” or “unreasonable,” no such qualifiers exist for MDD. Aside from the bereavement exclusion, the diagnostic criteria do not take into account the context in which symptoms arise.

Ample scientific evidence—ranging from infant and primate studies to cross-cultural studies of emotion—suggests that intense sadness in response to a variety of situations is a normal, biologically designed human response. Recent epidemiological analysis suggests that the consequences of stressors can be either normal or abnormal, similar to those for bereavement.^[1] In its quest for reliability via symptom-based definitions that minimized concern with the context in which the symptoms appeared, DSM unintentionally abandoned the well-recognized, scientifically supported, indeed commonsensical distinction between normal sadness and depressive disorder.

The blurring of the distinction between normal intense sadness and depressive disorder has arguably had some salutary effects. For example, it has reduced the stigma of depression and created a cultural climate that is more accepting of seeking treatment for mental illness. Many people with normal sadness might benefit from medication that ameliorates their symptoms. However, the usefulness of medication for normal sadness, and especially the trade-off between symptom reduction and adverse effects, has not been carefully studied—partly because the necessary distinctions do not exist within the current diagnostic system.

The decontextualized definition of MDD, however, has had substantial costs. Since 1980, an enormous “medicalization” of unhappiness has occurred. Life’s ills—whether a failure to attain an expected promotion, ongoing conflict with a spouse, or overwhelming distress from coping with competing family and work demands—are too often treated as mental disorders based on the report of a few symptoms of sadness. The medicalization of social life triggered an immense rise in the consumption of antidepressants. The efficacy of these medications for the treatment of normal sadness is often overstated, and their potential to cause harmful effects has sometimes been underestimated.

The consequences of over-medication is particularly worrisome for children and adolescents who are being socialized into a belief system that equates personal suffering with mental disorder to be overcome by taking a pill. The blurring of normal sadness and depressive disorder might also be proceeding at the expense of the smaller group of people who have a true psychiatric disorder and who are in desperate need of adequate psychiatric treatment.

Psychiatrists need not be moralists, judging whether patients should or should not take medication for life’s normal disappointments and suffering. It is, however, each psychiatrist’s responsibility to diagnose as fully and as accurately as possible, and not to bias the patient’s decision regarding treatment by a diagnosis that mistakenly labels as a disorder what is likely a normal response that will abate on its own as the patient copes with a difficult life change. Watchful waiting as well as a range of empirically tested psychotherapeutic interventions that are demonstrated to be as effective as medication for treating nonsevere conditions might be substituted for prescriptions in such cases.

It might seem that the results of epidemiological studies show that there are vast numbers of patients with untreated pathology in the community who may benefit from psychiatric care. In fact, such estimates place the credibility of psychiatry at risk and make the field a target of media ridicule. Can anyone truly believe, as the WHO evidently does, that the one-tenth of the population it estimates to have MDD in a given year has a condition of equal severity on average to paraplegia or blindness? Artificially high prevalence rates and the consequent policy emphasis on unmet need for mental health treatment and prevention are well-intentioned; however, this can have the counterproductive effect of transferring scarce treatment resources from persons with MDD to those who do not have the disorder.

The American Psychiatric Association is currently developing DSM-V. It will have the opportunity to supplement the symptom-based definition of MDD with a definition that emphasizes the importance of context in determining whether a given collection of symptoms indicates a mental disorder. One way to do this would be to follow the model of the anxiety disorders that often requires that symptoms be “excessive” or “unreasonable” relative to the context in which they arise. Alternatively, a new definition might build on the bereavement exclusion and also exclude conditions that arise from other major psychosocial stressors that are not unusually severe or prolonged.

It is possible that incorporating context into the diagnosis of MDD could make diagnoses more difficult in some cases and decrease reliability. Yet, the improved validity that should follow from more contextual diagnostic criteria would enhance the authority of the psychiatric profession. Most important, it would benefit people with either normal sadness or genuine mental disorders who deserve accurate diagnoses and the safest and most specific and effective treatments.

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Reference

1. ↑ Wakefield JC, Schmitz MF, First MB, Horwitz AV. Should the bereavement exclusion for major depression be extended to other losses? Evidence from the National Comorbidity Survey. Arch Gen Psychiatry. 2007;64:433-440.