Guidelines May Encompass Many Who Are Just Sad
By Shankar Vedantam
Washington Post Staff Writer
Tuesday, April 3, 2007; A02
Up to 25 percent of people in whom psychiatrists would currently diagnose depression may only be reacting normally to stressful events such as a divorce or losing a job, according to a new analysis that reexamined how the standard diagnostic criteria are used.
The finding could have far-reaching consequences for the diagnosis of depression, the growing use of symptom checklists to identify those who may be depressed, and the $12 billion-a-year U.S. market for antidepressant drugs.
Diagnoses are currently made on the basis of a constellation of symptoms that include sadness, fatigue, insomnia and suicidal thoughts. The diagnostic manual used by doctors says that anyone who has at least five such symptoms for as little as two weeks may be clinically depressed. Only in the case of someone grieving over the death of a loved one is it normal for symptoms to last as long as two months, the manual says.
The new study, however, found that extended periods of depression-like symptoms are common in people who have been through other life stresses such as a divorce or a natural disaster and that they do not necessarily constitute illness.
The study also suggested that drug treatment may often be inappropriate for people who are experiencing painful -- but normal -- responses to life's stresses. Supportive therapy, on the other hand, may be useful -- and may keep someone who has been through a divorce or has lost a job from going on to develop full-blown depression.
The researchers -- including Michael B. First of Columbia University, the editor of the authoritative diagnostic manual -- based their findings on a national survey of 8,098 people. They found that those who had experienced a variety of stressful events frequently had prolonged periods in which they reported many symptoms of depression. Only a fraction, however, had severe symptoms that could be classified as clinical depression, the researchers said.
An estimated one in six Americans suffer depression at some point in their lives. Under the more limited criteria the researchers urged, that number would be 25 percent lower.
"The cost of not looking at context is you think anyone who comes under this diagnosis has a biological disorder, so should more or less automatically get antidepressant medication, and everything else is superfluous," said lead author Jerome Wakefield, a New York University researcher who studies the conceptual foundations of psychiatry. "There is a trend to treat people in this somewhat mechanized way."
Said First: "One issue this would play out at is at the level of medication. If someone has a normal grief reaction, you wouldn't give that person an antidepressant, you would favor counseling. If someone has major depression you would be more likely to medicate. So this could influence how clinicians think about medications or psychotherapy."
Drawing the line between normal and abnormal suffering has long been controversial in psychiatry, because people who have no disorders often experience the same symptoms as those who do, but their reactions typically are less prolonged and intense. Where to draw the line involves a degree of subjective judgment: If the criteria are too strict, some people who are depressed may not receive help.
After First oversaw the writing of the current edition of the manual, for example, a number of doctors contacted him about difficulties they had in applying the diagnosis, First said. One described a patient who was feeling acute grief after the death of her dog. The manual says doctors need not diagnose depression if symptoms follow the death of a loved one, and the doctor wanted to know whether the death of a pet met the criterion.
That question, First said, illustrated how difficult it was to establish a set of criteria that could encompass the complexity of human sorrow: The death of a spouse or a family member, he said, was only one of many things that could cause an acute grief reaction.
But he warned that people who are in pain after a divorce or other stressful event should not conclude that they simply ought to "buck up." They should seek the counsel of clinicians who would take the time to explore what caused the symptoms and whether they need treatment.
Still, Wakefield and Allan Horwitz, a researcher at Rutgers University who studies the sociology of mental disorders, said their study, which was published in this month's issue of the Archives of General Psychiatry, pointed out that sadness has increasingly come to be seen as pathological in the United States. They have written a book called "The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder."
Pharmaceutical companies, the psychiatric profession and patient advocacy groups have all contributed to the phenomenon, Horwitz added. Companies stand to make more money from the one-size-fits-all approach, researchers find the cookie-cutter model of disease makes it easier to do studies, and psychiatry has come to think of itself as "the arbiter of normality," he said.
Patient groups, Horwitz added, think that the stigma attached to mental illnesses would be reduced if they were shown to be more common.
"The way in which people interpret their emotions is changing," Horwitz said. "People are starting to think that any sort of negative emotion is unnatural, that they can take medication and feel better. What that can also do is . . . make it less likely for people to make real changes in their lives that might be better than medications."