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.