An Epidemic of Depression

“An Epidemic of Depression” by Wakefield and Horwitz (Psychiatric Times, November 2008, page 44) raised the issue that DSM does not take into account the context in which symptoms arise for the diagnosis of MDD. The authors opine that the diagnosis should require that symptoms be “excessive” or “unreasonable” relative to the context in which they arise, and that “the efficacy of these medications for the treatment of normal sadness is often overstated.”

This is really a discussion of whether first–episode reactive depression should be considered a type of MDD, even if the symptoms are considered “excessive” given the context. (Certainly, persons with recurrent endogenous depression do not need much stress to have a relapse). Some persons react to high stress levels and develop a disorder and some do not (it is now known that holding the short form of the serotonin transporter gene is a risk factor for MDD).

While the authors note that a few symptoms of sadness related to “overwhelming” distress may be “too often treated as a mental disorder,” they do not operationally define “a few symptoms of sadness.” If the stress is “overwhelming,” then it makes sense that many persons will succumb to MDD as a result. I think that most psychiatrists would only give an antidepressant to someone with a first episode of reactive depression in which there are concerning cognitive and/or vegetative symptoms that persist despite psychotherapy; in this setting, they may also consider a short course of a soporific or minor tranquilizer.

My vote is that each patient needs to be looked at individually and treated based on the clinical judgment of the physician, who should take past and family history into account. Including criteria for excessive reaction to stress in DSM goes against the recent genetic and neuroscience findings that support the clinical experience of MDD seen in a variety of stress contexts and may lead to a delay in medical intervention when needed.