Randolph M. Nesse, MD

The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder
by Allan V. Horwitz 
and Jerome C. Wakefield; New York: Oxford University Press, 2007
312 pages • $29.95 (hardcover)

When historians try to understand why psychiatric diagnosis abandoned validity for the sake of reliability in the years surrounding the millennium, they will rely on The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. In measured tones and exacting prose, Horwitz and Wakefield deliver not only a devastating critique of the DSM diagnostic criteria for depression but also a thoughtful and authoritative assessment of how they came to exist and persist.

Their main point is simple. For thousands of years physicians relied on the presence or absence of an adequate cause to distinguish ordinary sadness from abnormal depression. Starting with DSM-III, however, consideration of causes was abandoned. Instead, any combination of a sufficient number, intensity, and duration of symptoms now suffices to diagnose major depression. There is one telling exception-symptoms that occur within 2 months of bereavement. Horwitz and Wakefield ask: What about those whose symptoms are precipitated by divorce or loss of a job? Do they all have mental disorders? Of course not.

The authors' analysis derives from Wakefield's definition of mental disorders as "harmful dysfunctions" arising from abnormalities in the evolved mechanisms that regulate emotions and behavior. Emotions, including negative emotions such as anxiety and sadness, exist only because they gave a selective advantage in certain situations. Normal and abnormal emotions can be distinguished only by determining if the person is in one of those situations. 

Loss is certainly the crucial situation that elicits sadness, but is depression just excessive sadness as the authors report? Many now believe that sadness and normal depression symptoms are aroused by different situations: respectively, a specific loss versus continuing pursuit of an unreachable goal. Horwitz and Wakefield review this research, but they do not pursue the implications, perhaps because the task of deciding what is and what is not normal is already problematic enough.

The authors also imply that drug treatment is appropriate mainly for persons with disorders. However, general physicians routinely use medications to block the suffering associated with normal protective responses, such as pain and cough. A genuinely medical model for psychiatry would try to find and correct whatever is arousing anxiety, depression, or other defensive responses. If the cause cannot be found or corrected, then treatment to block the defense and relieve suffering is entirely appropriate. However, general physicians know the purpose of pain and cough. Psychiatrists lack comparable knowledge about when low mood is useful. This is the missing foundation on which scientific diagnostic criteria for depression will eventually be constructed.

For now, Horwitz and Wakefield's suggestion is sensible; the diagnosis of major depression should be excluded if symptoms result from major life events. If this book cannot change the DSM criteria for depression, nothing will. The authors emphasize how many interests converge to block major corrections in DSM. That seems right. But I will wager that future historians will give equal weight to current psychiatry's imitation of the reductionist methods that have worked so well in the rest of medicine, even though what we lack is a functional understanding of emotions comparable to the functional framework physiology offers for the rest of medicine.
 

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When historians try to understand why psychiatric diagnosis abandoned validity for the sake of reliability in the years surrounding the millennium, they will rely on The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder.