Some features may distinguish BRD from depression triggered by other losses or stressors. These include lower rates of seeking professional treatment8 and less interference with life activities in BRD.9 However, there are deep clinical and epistemological problems in the notion of a unique “trigger” for a depressive episode; for example, chronological distortions in a patient’s recollection of depression onset1,4 and the presence of underlying medical factors.4 Indeed, I believe the construct of a depressive “trigger” is nebulous and empirically unverifiable, except perhaps in highly unusual scenarios (for instance, a euthymic subject is injected with a powerful, short-acting biogenic amine-depleting agent; severe depressive symptoms develop within 2 hours and then spontaneously remit over the next 12 hours).

The appeal to “tradition”
Horwitz and Wakefield repeatedly invoke what they call the “2500-year history of psychiatric medicine”2,3 in defending their depression “with cause versus without cause” distinction. Citing Aristotle, Felix Platter, and Emil Kraepelin, they argue that only depressive syndromes “without cause” were considered “mental disorders” throughout most of medical history.3(p58) Our modern diagnostic schema, they maintain, “radically diverges from what has traditionally been considered appropriate.”3(p53)

Let us put aside the suspicion that this argument is essentially an appeal to “eminence-based medicine.” We must still ask whether the “with cause versus without cause” distinction is really representative of how most physicians actually thought and acted during the entire 2500-year history of medicine. H. C. Erik Midelfort, professor of history at the University of Virginia, and author of the book, A History of Madness in Sixteenth-Century Germany (Stanford University Press), comments on this as follows: “. . . for ancient and early modern physicians, there was no clear, bright line between disease and health. They did not, generally, decide that someone was suffering an understandable and proportionate sadness and was not therefore ‘ill.’They generally decided that if one were suffering, for whatever reason and whether proportionate or disproportionate, they would do what they could to help . . . [and their remedies] did not depend upon a strict decision that so-and-so was fundamentally ‘ill’ while someone else was merely sad for good, sufficient, and proportionate reasons” (personal communication, October 2008; italics added).

Indeed, the physician’s primary role has always been to relieve suffering and incapacity—not to act as an amateur evolutionary biologist and sit in lofty judgment, as regards how “proportionate” a patient’s response is to some putative stressor.

Is there really an “epidemic” of depression?
Epidemiological data from the 1980s indeed suggested that the incidence of depressive disorders in cohorts born since WWII has been increasing in some countries, such as the US, Sweden, and Germany.10 However, recent, multi-decade epidemiological data from both the Baltimore ECA (epidemiological catchment area) Study11 and the Lundby Study12 from Sweden strongly suggest that the incidence of depression over the past 30 to 50 years has remained more or less the same, with the possible exception of rising rates in women. Both of these studies employed criteria similar to the “precipitant-neutral” criteria of DSM-III and IV.

To be sure, Horwitz and Wakefield do not claim that that there has been an “actual increase” in rates of depressive illness.3(p4) Rather, they point to “the recent pandemic of seeming depressive disorder,” which they unambiguously attribute to “changes in the psychiatric diagnostic system presented in DSM III.” 2 Furthermore, they believe that virtually all community-based epidemiological studies of depression since the late 1970s are contaminated by “false-positive” diagnoses of depression, owing to their decontextualized DSM criteria.3

But this notion of false positives is troubling on several levels. First, we do not have a veridical “test” for depression— akin to, say, detecting Treponema pallidum in syphilis—that would demonstrate that subjects have been “falsely” diagnosed as depressed, by DSM criteria. Nor, as healers, should we insist on such a test. Furthermore, the claim that epidemiological studies of depression produce many “false positives” assumes as true precisely what Horwitz and Wakefield have yet to prove: namely, that we should not “count” cases of BRD as depression. This would be analogous to a cancer researcher arguing that we should exclude mesothelioma cases that appear to be “provoked” by environmental exposure, without first demonstrating that such “precipitated” cases differ in their pathophysiology, course, outcome, response to treatment, etc, compared with spontaneous cases.

As for reports of rising rates of “depression” as a psychiatric diagnosis and increased antidepressant prescribing rates in recent years,3(p187) these trends are probably driven by numerous factors. These include increased public awareness of depression; increased help-seeking; exposure of both patients and physicians to “Big Pharma” advertising; and pressure exerted by third-party payers to provide “reimbursable” diagnoses. These trends are certainly worrisome, but they cannot confidently be attributed to changes in our diagnostic criteria for depression. Indeed, I believe that overdiagnosis of depression—to the extent it occurs—often results from a failure to apply DSM criteria stringently, rather than to their use. This, however, is a conundrum that requires much more study. In my experience, I have observed what I call the “twin peaks” phenomenon: ie, underdiagnosis of depression in some clinical settings and overdiagnosis in others.

My objections to the H-W thesis should not be misconstrued as an endorsement of current DSM-IV criteria for major depression. Among several other problems,13 the 2-week duration criterion may be too brief (S. Zisook, personal communication, November, 2008). Extending it to 3 to 4 weeks might slightly decrease sensitivity but could increase specificity. Only carefully conducted longitudinal studies of depression outcome will decide the matter. But extending the duration criterion for MDE has nothing to do with attributing “special properties” to depression in the context of loss. It simply reflects the clinical observation that depression of only 1 to 2 weeks’ duration may spontaneously remit in some patients, given another 2 to 3 weeks.

Neither do I mean to suggest that the DSM’s categorical system of diagnosis represents the pinnacle of psychiatric wisdom. I and many others have long believed that a “dimensional,” psychodynamic, spiritual, and phenomenological understanding of grief and depression should complement and enrich the DSM categories.14-18

A heart attack is a heart attack
Dr Zisook has observed that when someone has a myocardial infarction (MI), physicians regard it as an instantiation of cardiac disease, regardless of its “context.” The MI may have occurred in the context of the patient’s poor diet, smoking, and high levels of psychic stress—but it is still an expression of disease. We do not try to “normalize” the MI by saying, “Well, you’d have a heart attack, too, if you had been exposed to that much stress!” (This is a version of what I call the “Fallacy of Misplaced Empathy.”19) To be sure, knowing the medical and psychosocial context helps us counsel and treat the post-MI patient, just as knowing the experiential and sociocultural context of a patient’s depression facilitates holistic treatment, as Dr Zisook observes (personal communication, November, 2008). And, in so far as Horwitz and Wakefield have shown us the importance of “context” in these respects, they have performed a valuable service. One hopes their book may also spark some much-needed research.

Nevertheless, as Maj1 concludes, “At the present state of knowledge, it may be . . . unwise to disallow the diagnosis of major depression in a person meeting the severity, duration, and impairment criteria for that diagnosis just because the depressive state occurs in the context of a significant life event.” Depression is a potentially lethal condition. It would be tragic if we inadvertently discouraged recently bereaved persons from seeking professional help, on the dubious presupposition that their depressive symptoms are merely “normal adaptations” to loss.

 
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