While researching this story, I came across a fascinating (and controversial) take on the “depression epidemic” called The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. It took a few months, but I’ve got a new interview with the authors up at Scientific American:
LEHRER: In your book, you take a critical look at major depressive disorder (MDD), a mental illness that will afflict approximately 10 percent of individuals at some point during their life. In recent decades, the number of cases of MDD has sharply increased. Are we currently experiencing an epidemic of depression? Or is this surge due to changes in diagnosis?
HORWITZ AND WAKEFIELD: Our book argues that, despite widespread beliefs to the contrary, the rate of depressive disorders in the population has not undergone a general upsurge. In fact, careful studies that use the same criterion for diagnosis over time reveal no change in the prevalence of depression. What has changed is the growing number of people who seek treatment for this condition, the increase in prescriptions for antidepressant medications, the number of articles about depression in the media and scientific literature, and the growing presence of depression as a phenomenon in popular culture. It is also true that epidemiological studies of the general population appear to reveal immense amounts of untreated depression. All of these changes lead to the perception that the disorder itself has become more common.
In fact, we think what has really changed is that since 1980 psychiatry and the other mental health professions have used a definition of depression that conflates genuine depressive disorder with intense, but normal, states of sadness. Since the third version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III) was published in 1980 psychiatry has relied primarily on a list of symptoms for its definition of depressive disorder. So someone who has five symptoms out of a list that includes things like depressed mood, loss of interest in usual activities, insomnia, fatigue, lessened appetite, an inability to concentrate and similar symptoms for as brief a period as two weeks is considered to have a depressive disorder.
Yet loss events such as a betrayal by a romantic partner, being passed over for a much-anticipated promotion, failing an important test, having a mortgage foreclosed, or discovering a serious illness in oneself or a loved one could naturally lead the same symptoms to arise and endure for a two-week period. When such criteria are applied to the general population, very large estimates of untreated depressive disorder emerge, because one is capturing intense normal reactions to losses as well as genuine depressive disorder.
Before 1980, for the 2,500 years since the dawn of psychiatric medicine, only symptoms that were “excessive” and inexplicable relative to their provoking context were considered to be signs of a depressive disorder. After 1980 all symptoms, even those that are proportionate to their provoking cause, were defined as disordered. This change means that intense natural reactions to loss events as well as disordered responses have been seen as mental disorders, thus accounting for the apparent increase in depression in recent years.