Sociology: medicalization of society essay

Asian Journal of Psychiatry 3 (2010) 96–98

Special article

Depression vs. ‘‘understandable sadness’’: is the difference clear, and is it relevant to treatment decisions?

Mario Maj

Department of Psychiatry, University of Naples, Naples, Italy

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Asian Journal of Psychiatry

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a j p

A R T I C L E I N F O

Article history:

Received 2 July 2010

Accepted 8 July 2010

One of the items of the ‘‘neo-Kraepelinian credo’’, articulated in the 1970s, was ‘‘there is a boundary between the normal and the sick’’. In other terms, it was maintained that there is a clear, qualitative distinction between persons who have a mental disorder and persons who have not (Blashfield, 1984). A corollary to this item was the statement that ‘‘depression, when carefully defined as a clinical entity, is qualitatively different from the mild episodes of sadness that everyone experiences at some point in his or her life’’ (Blashfield, 1984). Apparently in line with this statement was the observation that tricyclic antidepressants were active only in people who were clinically depressed; when administered to other people, they did not act as stimulant and did not alter their mood.

Today, the picture appears much less clear, and this is certainly in part a consequence of the evolution of psychiatric treatments. Guidelines for treatment of major depression often contain contradictory statements in this respect: on the one hand, the assertion that it is important to clearly differentiate clinical depression from normal adaptive responses to stress; on the other, the warning that antidepressant medications are effective even in the presence of significant life stress, and should not be withheld solely because the condition is understandable. These statements beget two questions: (a) Are we really able to distinguish between a ‘‘dysfunctional’’ and an ‘‘adaptive’’ response to an adverse life event? (b) Is this distinction clinically relevant, since treatment decisions are expected not to be influenced by whether the condition is understandable or not, but only by its clinical picture, severity, duration and by the degree of impairment of social functioning? These are questions with significant political, ethical, scientific and clinical implications, which have become particu- larly visible and pressing in the past few decades, in parallel to the escalation of the prevalence rates of depression in community

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studies, of the estimated social costs of depression, of the number of patients in treatment for depression, and of the prescriptions of antidepressant medications.

The National Comorbidity Survey, published in 1994, reported that the 1-year prevalence of major depression in the US adult community was about 10%, and the lifetime prevalence about 17% (which means that one out of 10 Americans currently suffers from major depression and almost one out of five has suffered from this disorder during his or her lifetime) (Kessler et al., 1994). The World Health Organization estimated that by 2020 depression will become the second leading cause of worldwide disability, and is already the leading cause of disability for people aged from 15 to 44 years: these estimates were based on the above data on the prevalence of depression in the community and on a severity score according to which depression was placed in the second most severe category of illness, the same category as paraplegia and blindness (WHO, 2001). In the US, the number of patients with depression treated in outpatient settings increased by 300% between 1987 and 1997, the use of antidepressant medications among adults tripled between 1988 and 2000, and the spending for antidepressants increased by 600% during the 1990s (Horwitz and Wakefield, 2007).

This situation has generated concerns from both outside and within the psychiatric profession.

On the one hand, psychiatry has been accused to inappropriately medicalize ordinary life problems in order to expand the range of its jurisdiction. This criticism was well articulated in a book entitled ‘‘Making us crazy. DSM: the psychiatric bible and the creation of mental disorders’’ (Kutchins and Kirk, 1997): ‘‘Determining when relatively common experiences such as sadness should be considered evidence of some disorder requires the setting of boundaries that are largely arbitrary, not scientific, unlike setting boundaries for what constitutes cancer or pneumonia’’. ‘‘Rather than gaining any substantive understanding of your difficulties, you gain [from the DSM-IV] a far more interesting glimpse of psychiatry’s struggle to define its domain and expand its range’’.

On the other hand, the above-mentioned prevalence rates of depression in the community have been regarded as unbelievable even from within the psychiatric profession: ‘‘Based on the high prevalence rates in both the Epidemiologic Catchment Area study and the National Comorbidity Survey, it is reasonable to hypothesize that some syndromes in the community represent transient homeostatic responses to internal or external stimuli that do not represent true psychopathologic disorders’’ (Regier

M. Maj / Asian Journal of Psychiatry 3 (2010) 96–98 97

et al., 1998); ‘‘The criteria diagnosed many individuals who were exhibiting normal reactions to a difficult environment as having a mental disorder’’ (Spitzer and Wakefield, 1999).

Particularly articulated has been the critique by Jerome Wakefield, an extensive version of which can be found in his book ‘‘The Loss of Sadness. How Psychiatry Transformed Normal Sorrow into Depressive Disorder’’ (Horwitz and Wakefield, 2007). The basic argument of this book is that the above-mentioned high prevalence rates of major depression, the WHO estimates about the social costs of this disorder, the high number of patients in treatment for depression and the increasing prescription of antidepressant medications are all consequences of the failure by DSM criteria to distinguish between true depression, a medical disorder which occurs despite there being no appropriate reason in the patient’s circumstances, and normal sadness, which represents a normal reaction to a major loss. What Wakefield proposes is either that the diagnosis of depression be ‘‘excluded if the sadness response is caused by a real loss that is proportional in magnitude to the intensity and duration of the response’’ or that the diagnosis of depression require that ‘‘despite there being no real recent loss (or only losses of minor magnitude), the individual nonetheless experiences a sufficient number and intensity of symptoms’’ (Wakefield, 1997). Thus, the proposal is to extend the current exclusion criterion concerning bereavement to other major losses.

This approach may sound reasonable, but is of doubtful feasibility and reliability. In the community, it is almost the rule that major depression is preceded by an adverse event, as reported by the patient. Wakefield himself, in a recent study (Wakefield et al., 2007), found that as many as 94% of cases of single episode major depression had been preceded by a loss. An additional contextual criterion may exclude from treatment a substantial proportion of people in need of it. The decision on whether there is a causal relationship between the event and the response and on whether the response is proportional to the event is often difficult, and would be left to the subjective judgement of the clinician, with a high risk of low reliability (Maj, 2008). Even worse, the ideological orientation of the clinician may sometimes be decisive: there are psychiatrists who do believe that every psychopatholog- ical manifestation can be explained by looking at the individual’s environmental conditions. Moreover, even when confronted with the most severe life events, only a small minority of individuals develop major depression, raising the issue of what is meant by a ‘‘normal’’ reaction to stressors (Kendler, 1999).

Actually, the point raised by Wakefield is not a new one. It was extensively explored by British psychiatry in the past. In particular, Aubrey Lewis described in a classical paper his attempt to apply a set of criteria to distinguish contextual vs. endogenous depression (Lewis, 1967). He reported that: ‘‘The criteria were applied . . . But the more one knew about the patient, the harder this became. A very small group of nine cases emerged where . . . it could be said the situation had been an indispensable efficient cause for the attack . . . There was a small group of 10 in whom one could not in the least discover anything in their environment which could have been held responsible for the outbreak of the attacks. But all the others were understandable examples of the interaction of organism and environment, i.e., personality and situation; it was impossible to say which of the factors was decidedly preponder- ant.’’.

It is useful to report that, although Wakefield maintains that the distinction between depression and normal sadness has to be done on the basis of the context in which the symptoms occur, because there are no significant symptomatological differences between the two conditions, there are some studies suggesting that the two conditions may actually be qualitatively different. ‘‘Normal forms of negative mood such as despair or sadness must not be mistaken as depressed mood, characterized by a lack of holothymia and

being an emotional feeling only known to depressed persons’’ (Helmchen and Linden, 2000). Along the same line, some studies carried out in patients with severe or chronic physical illness have described the differential features between clinical depression and understandable demoralization. A depressed person has lost the ability to experience pleasure generally, whereas a demoralized person is able to experience pleasure normally when he is distracted from thoughts concerning the demoralizing circum- stance or event. The demoralized person feels inhibited in action by not knowing what to do, feeling helpless and incompetent; the depressed person has lost motivation and drive even when an appropriate direction of action is known. Moreover, persons with clinical depression suffer from psychomotor, neurovegetative and cognitive symptoms which are not typically present in demorali- zation (Clarke and Kissane, 2002).

However, the evidence provided by taxometric analyses of depression carried out in large clinical samples suggests that major depression is not qualitatively distinguishable from less severe mood states, although these analyses do not completely exclude the existence of a latent depression taxon corresponding to ‘‘endogenous’’ or ‘‘nuclear’’ depression (Grove et al., 1987).

Another critical point concerning Wakefield’s approach is that the treatment implications of a distinction between intense understandable sadness and non-contextual depression are cur- rently unclear. Actually, there are studies showing a high rate of response to antidepressant medication in people who meet diagnostic criteria for a major depression episode during the first 2 months of bereavement, which has led Zisook et al. (2007) to conclude that even the current DSM-IV exclusion criterion concerning bereavement may not be valid (so, rather than extended to other losses as proposed by Wakefield, it should be eliminated). Furthermore, some psychotherapeutic techniques which have been proven to be effective in major depression, namely interpersonal psychotherapies, are based on the assumption that the individual is currently experiencing problematic environmental situations, of which the depressive condition is an understandable consequence.

In his book, Wakefield mentions the argument that treating intense understandable sadness may disrupt normal coping processes and the use of informal support networks. In fact, it has been repeatedly pointed out in the literature that externally elicited, mild to moderate, depressive states may have an adaptive role that has developed through the evolution of the human species. They may warn a person that past or ongoing strategies have failed and new strategies are needed. Physiological slowing and social withdrawal may remove a person from high-cost, low-benefit social interactions, and signalling one’s state to others may initiate others’ help without requiring long-term payback. In this light, the experience of mental suffering is developmentally useful and even necessary for human growth and self-actualization. By medicalizing this condition and treating it with drugs we may undermine the coping strategies of the individual (McGuire and Troisi, 1998). The opposite view, however, is that suffering in itself does not promote any growth and self-actualization, and that what makes sense from an outside, universal philosophical perspective becomes unaccept- able if we try to say that the intense suffering of that particular person in real time and space ultimately exists for his own good. In this light, the relief of severe mental suffering by appropriate, clinically sound means becomes a legitimate medical purpose, exactly like the relief of severe physical pain (Bjorklund, 2005). This is, if you wish, the philosophical side of the problem. The clinical and scientific side is that the effectiveness and cost-effectiveness of pharmacological and non-pharmacological interventions for intense understandable sadness has to be proved by research.

One view which has been repeatedly expressed in recent years is that the boundary between mental disorders and normality can be decided only arbitrarily on pragmatic grounds (Kendell and

M. Maj / Asian Journal of Psychiatry 3 (2010) 96–9898

Jablensky, 2003). The boundary will be regarded as clinically valid if it has significant predictive implications in terms of response to treatment and clinical outcome. However, if prediction of treatment response is going to be one of our validating criteria in the case of the diagnosis of major depression, it is unlikely that the threshold for the diagnosis will be the same for all the various treatment modalities which are currently available. The threshold for response to an interpersonal psychotherapy, for instance, may be different from the threshold for response to an SSRI, which may be different from the threshold for response to a tricyclic antidepressant. This provides a rationale for the recent proposal of sequential stepwise treatment algorithms for people with depressive symptoms (Linden et al., 1994). Should we ignore the issue of the differential diagnosis between true depression and understandable sadness and simply apply one of these algorithms to all people presenting with depressive symptoms? In a community setting, this could be a reasonable response to the current state of affairs.

So, in conclusion, our initial questions, whether we are able to distinguish between a ‘‘dysfunctional’’ and an ‘‘adaptive’’ response to an adverse life event, and whether this distinction has significant treatment implications, remain without a clear answer at the moment. What we really need is further research evidence concerning the feasibility and reliability of the addition of a ‘‘contextual’’ criterion in the diagnosis of major depression, the clinical utility of this additional criterion in terms of prognosis and prediction of treatment response, and the biological correlates of non-contextual depression vs. normal sadness, and probably also further research efforts aimed to operationalize that ‘‘distinct quality of mood’’ which may distinguish at least some forms of depression from normal sadness. The more these issues appear to be loaded with political and ethical implications, the more they require objective and convincing research evidence.

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