Book Review / MEREDITH L. THEEMAN
The Trouble with Sadness
- The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. By Allan Horwitz & Jerome Wakefield. Oxford University Press, 2007 (312pp).
Do you know the difference between sadness and depression? How long is it “ok” to feel really sad after a loved one dies? Should feeling down when your partner is diagnosed with cancer be considered depression? Or is it just a rational response to an unfortunate situation? Answers to these questions often touch upon issues of cause, culture, family history, functionality, or diagnosis. Allan Horwitz and Jerome Wakefield’s new book The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder boldly and insightfully looks at the way we as a society have been trained to think about depression and sadness. Taking its readers through the rich and intriguing history of depression, Loss of Sadness then uses these accounts to critique the current psychiatric diagnoses for depression.
After carefully deconstructing components of clinical criteria, Horwitz and Wakefield contend that definitions of depression as written in the American Psychiatric Associations’ Diagnostic and Statistical Manual of Mental Disorders (DSM) do not exclude enough people from being labeled with psychologically disordered sadness. The authors argue that people feeling badly in response to stressful personal experiences (like job loss, relationship break-up, illness diagnosis) or ongoing social situations (such as poverty, repressive government, war) should be viewed differently than those people with endogenous, or naturally occurring, depression.
In a nation where more people take antidepressants than any other class of prescription drugs, a frank discussion of what is and is not clinically viable depression, has been long overdue. Those familiar with the research literature will know that this has, indeed, been a conversation on the margins for years. This book complements other critiques of psychiatry and mental health treatment including Christopher Lane’s recent Shyness: How Normal Behavior Became a Sickness, Carl Elliot’s Better Than Well: American Medicine Meets the American Dream, Paula Caplan’s They Say You’re Crazy, and the work of David Healy (best known for Let Them Eat Prozac).
What makes Loss of Sadness so exciting is that it shifts sheltered conversations about the validity of “depression” out of academic and clinical realms and onto the streets where people affected by sadness and depression can talk about the ramifications of naming intense periods of sadness as clinically depressed episodes, thereby educating one another as consumers of psychiatric services.
The authors note that the DSM-III represents a view of depression that stands in contrast to the “critical traditional distinction” between sadness in response to life events and endogenous depression resulting in an “ultimately detrimental conceptual shift” such that the modern perception of depression no longer considers circumstances of psychological distress, instead focusing on “decontextualized criteria” to determine diagnosis. Up until the DSM-III, “cause” was the primary determinant of abnormal sadness. Horwitz and Wakefield take their readers back 2,500 years to references of melancholia by Hippocrates to illustrate this point: “If fear or sadness last for a long time it is melancholia.” At a time when there were few conceptual categories of abnormal behavior, melancholia generally referred to something wrong within the person, not the surroundings, due to imbalances of black bile in the liver. Aristotle postulated the problem of “proportionate” sadness in such a way that severity and length of sadness appropriate to the circumstances that caused it were not considered disordered. Only those experiencing dysfunctional sadness “without cause” were considered diseased.
The authors highlight Robert Burton’s description of the depressive phenomenon as having cognitive, mood, and physical components in his 1621 The Anatomy of Melancholy. His emphasis on these three components as well as the variation in symptom expression would echo into the twentieth century.
Interestingly the terms melancholia and the more modern melancholy were used for hundreds of years with similarly broad strokes as “depression” today, referring to both disordered sadness and feeling low. But just as melancholy could be separated from sadness by asking whether or not the feelings arose “with or without cause,” so too can depression, the authors argue.
Why bother with the differentiation? Beginning with a reminder that psychiatry should not unnecessarily burden healthy people with labels of illness and its subsequent social stigma and prejudice, Horwitz and Wakefield convincingly delineate the reasons why normal sadness can, and should, be differentiated from dysfunctional depression. While conflating the two forms of sadness places unrealistic expectations for course of treatment and remission on those with disordered sadness, separation of these phenomena may lead to greater prognostic and treatment accuracy in part because patients’ expectations for the future will be more appropriate.
The authors argue that these expectations will be formed, in large part, by future research outcomes based on participant samples that are definitively disordered. As it stands now:
“The causes of depressive symptoms that arise from dysfunction are generally different from the causes of normal sadness, so the entire field of depression research remains problematic until the appropriate distinction is made.”
Invalid diagnostic criteria and research outcomes also invalidate epidemiological studies seeking to estimate how frequently people have depression in a given population and which factors contribute to their insulation against or exposure to risk for depression. If people with normal sadness are counted as disordered, Horwitz and Wakefield note, epidemiologists will overestimate the number of people suffering, in turn “misleading policy makers into formulating poor public policy.”
So what? If our calculated prevalence rates for depression do not match up with surveys tracking actual cases in the population, those in charge of healthcare policy are likely to assume that there is a “vast amount of unmet need for treatment.” This can lead policymakers (or those who can profit from certain policies) to push for “widespread screening for depression among people who have not voluntarily sought treatment.” This means that we advocate the process of hunting out people with depression in places like schools using brief screening tests that often fail to consider people’s current life experiences. Failure to take into account the context of people’s sadness (like being teased at school or breaking up with a boyfriend or girlfriend) can result in a lot of people being diagnosed as depressed. Horwitz and Wakefield foresee that “the reduction of such overdiagnosis could reduce the needless and potentially harmful overprescription of medication.”
Another reason to unravel normal sadness from clinical depression is to help researchers gain a better understanding of the dynamic between sadness and stressful life experiences. Our lives involve varying levels of unavoidable challenges and hardship; enhanced comprehension of our responses to these challenges could lead to more effective ways of preventing and mitigating stress and sadness. Already there is evidence to suggest that people can control many factors related to managing stress, sadness, and grief. Medical research advocates for the maintenance of healthy lifestyles that emphasize well-rounded diets and exercise as to encourage well-being and prevent illness. The field of Environmental Psychology has produced research indicating that more humane work environments, increased access to the outdoors and natural light, and safe neighborhoods may help mediate stress in our daily routine so that we can more effectively handle times of sadness. Public health strategies can be used to educate communities and policymakers about differences between dysfunctional depression and normal sadness.
If “the long-term credibility of psychiatry and psychiatric diagnosis depends on getting the disorder-nondisorder distinction right”, the field owes a big thank you to Horwitz and Wakefield. A diagnostic framework that narrowly focuses on symptoms casts a wide net, catching sadness, depression, and dysfunction all at once. The ramifications of medicalizing normal, yet intense, expressions of sadness are far reaching for affected individuals and the field itself, which may come off as being overly aggressive. Shifting priorities toward holistic frameworks for assessment will help psychiatry “look good” because its diagnostic labels will be more reliable and valid.
While not a goal of the book, it is disappointing that Horwitz and Wakefield do not take the time to describe endogenous, or naturally occurring, depression. A clearly articulated definition of this pathology would have provided a stark contrast to the experiences of intense sadness on which they focus, likely assisting readers less informed on these topics.
By the end of the book the authors’ main point is clear: the symptom-based structure of the DSM criteria fails to differentiate normal periods of intense sadness from episodes of disordered depression, resulting in an immense problem with the construct validity for depression. This creates misconceptions about the frequency of depression in our communities, what are “normal” responses of sadness to challenging or stressful life events, and how we should care for those who truly are sad in reaction to personal loss or stressful life events such as war, homelessness, or poverty, but not endogenously depressed. Subsequent health policies, screening and treatment protocols, epidemiological counts, and research data conceived in accord with the diagnostic criteria similarly compound the impact of this conflation of sadness and depression.
Readers are left with a sense that because the notion of “depression,” as anything mirroring the DSM’s symptom criteria, is so deeply entrenched in the minds of researchers, clinicians, healthcare companies, and our community-at-large that redefining it is going to be a difficult, yet surmountable challenge. In closing, Horwitz and Wakefield brush through a few suggestions regarding resolving the problem they have so meticulously laid out for their readers.
Their suggestions either amend or add to pre-existing systems used to define or screen for depression. On the surface some suggestions are seemingly simple like the idea to convince the writers of the upcoming DSM editions to broaden exclusion criteria so that people whose sadness comes in response to changes in relationships, work status or other life events would join those experiencing the loss of a loved one as disqualified for a diagnosis of depressive disorder. However, Horwitz and Wakefield realize this proposal may be challenged by the organizational complexities within the American Psychiatric Association as well as its close relationships with the healthcare industry.
Because a substantial number of people are diagnosed with and/or treated for depression at their primary care physician’s office, Horwitz and Wakefield suggest implementing new screening protocols. This would require a shift in thinking because this approach would involve changing the way in which medical practitioners look for, diagnose, and treat depression.
Ideally practitioners would better examine why their patients are feeling down and emphasize the need for psychological evaluation when appropriate (instead of making a hasty diagnosis and writing a prescription for anti-depressants during a seven minute check-up). The authors argue that supporting new protocols with an overhauled screening checklist could better uncover recent life experiences that might contextualize the cause of people’s depressive feelings. If practitioners could see these changes as valuable, time-saving, cost-effective, and better for their patients, then periods of intense sadness might be less likely to be classified as clinical depression.
Unlike some books of similar genre, Loss of Sadness does not point fingers or specifically assign blame regarding the current, problematic state of psychiatry’s conceptual validity. Robert Spitzer’s authorship of the book’s foreword attests to this point. Architect of the DSM’s third edition, which introduced the symptom-based system of assessment, Spitzer is one of the strangest bedfellows imaginable. Conveying an evolved view, Spitzer notes that the DSM’s “criteria specified the symptoms that must be present to justify a given diagnosis but ignored any reference to the context in which they developed. In so doing, they allowed normal responses to stressors to be characterized as symptoms of disorder.” His endorsement that “psychiatry will rest on firmer logical foundations as a result” of the book may likely be as pivotal for change as the book itself.
By eloquently presenting a rational historic and theoretical analysis of the concept of depression, Horwitz and Wakefield’s Loss of Sadness acts as the burden of “proof” needed to justify re-conceptualizing clinical depression and intense sadness as separate entities. At times a bit weighty and difficult, I hope that this tremendous effort will resonate with many; not just those whose decisions directly impact the defining, screening, and treatment of depression, but those seeking solace and assistance from our healthcare system as well.
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