The Depression Epidemic

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.

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What I think the critics of depression miss is that virtually no one seeks help after the two weeks required for the diagnosis. I know no one on antidepressants (and I know many on them!)who didn't suffer for months-- most suffered for years-- before they agreed to seek help.

Maybe these people creep into the population studies-- but I somehow doubt it.

I'd like to see statistics on the people diagnosed or included in population samples who had just two weeks of symptoms-- I'd bet the proportion is miniscule. Without knowing this, the critique is really not valid.

By Maia Szalavitz (not verified) on 08 Dec 2008 #permalink

I agree with you maia. In fact, I'll go further, most people (my family and freinds who are on meds) fought for years against going to docs for help and meds. (but then I saw the same thing with folks fighting ADHD diagnoses, so maybe i hang with a weird crowd of non-pill wanters)

Perhaps there should be a page link for suggestions for more scientists we wish Jonah would interview.
Maintaining an open dialogue on social, medical and neuroscience intersections is so important, especially with misinformation and oversimplification making headlines, and substantive material getting far less attention.
Getting help for any problem requires a multifaceted approach tailored to that particular individual's family history, current situation and overall medical condition just for starters. It's great to have another lucid JL post to be able to send to those who trust pills over people.
From happiness to sadness in the last 2 posts. Do we get rage tomorrow?

Luci's post is outstanding:

Here is a thought.

"There is a compact among the learned not to pass beyond a certain limit in speculative science"
Samuel Taylor Coleridge

By OftenWrongTed (not verified) on 08 Dec 2008 #permalink

I'm stilling waiting to get my hands on a copy of How Sadness Survived. Reviews indicate his theories and advice are speculative, and that his empirical evidence is spotty; still, it sounds like an accessible entry point.

Independent of rates of depression, one must ask is there more "loss" in the world today. Even in these trying economic times, many people have a standard of living greater than previous generations. Now, they have hopes that may not be realize.
Perhaps the question is how do people move from loss to depression, or better yet, what can one do to prevent oneself from moving into the depression. Personally, I think a two week period is perhaps too short (and certainly, too arbitrary) to deal with the sadness of disappointment.

By Elizabeth (not verified) on 08 Dec 2008 #permalink

"I know no one on antidepressants [snip] who didn't suffer for months-- most suffered for years-- before they agreed to seek help."

We all want to be normal. The hope is that if we can tough it out for a few days, weeks, or months, we will finally - by virtue of us surviving the pain - be able to be real normal people. Pinocchio is a role model!

By oscarzoalaster (not verified) on 08 Dec 2008 #permalink

I have wondered for some time if some of the blame for depression cannot be laid at our culture's denial of sadness and grief. A hundred years ago a bereaved person wore outward signs of mourning and was not expected to participate in society as if nothing in their personal life had changed.

I don't wish to put on black for a year, but I could happily miss the "Have a Nice Day" comments forced on me by store clerks while I shop for groceries for a funeral lunch.
( A note to store owner's - I find " Did you find everything you were looking for?" more neutral and more relevant.)

The expectation that life should continue as normal one week after a death or other tragedy will make people that need more time to get their act together feel even worse. They are set up to see their grief as a personal failure
rather than an honest reaction to their cicumstances.

I also hate the whole concept of "closure". The media seems to think that for every tragedy there is some formula for bringing "closure" so if you just find the right steps everything will be okay.

Sorry - by definition, a tragedy is an event that profoundly changes your life, so that nothing ever will be the same again. It takes time to find a new equilibrium. You may never again be as carefree as you once were. That's life.

In addition, some life events like job losses, miscarriages, broken engagements etc. are dismissed as minor by people who never experienced them. I once met a woman who was furious with her friend who was looking for sympathy when her husband's business went bankrupt. She was a widow and felt that her friend, with a living husband could have no problems at all. Sorry, that woman lost her husband too. No way will he ever again be the man she married. But no one will send cards or flowers. In fact, they will avoid her. Social isolation - another contributor to depression.

True depression is a terrible thing. I think it is possible for otherwise healthy people to find themselves spiralling downward when life is truly difficult, and I hope someday we can have more understanding of how to prevent that.

The authors are describing an adjustment disorder, which many clinicians (including myself) believe is a more responsible diagnosis when you only have symptoms presenting for two weeks resulting from a life stressor. Adjustment disorder is not as stigmatizing, allows for insurance companies to be billed, and possibly prevents the extreme downward spiral that can be legitimate major depression. Last I checked adjustment disorders made up over 30% of all outpatient insurance claims, which is considerably higher than any other DSM-IV disorder.

Psychiatry and Psychology are still in their infancy, but using a medical model of gray symptoms (DSM-IV) to attempt to describe the phenomenon that is the human psyche/condition is like trying to use the bohr model to explain quantum physics. But it's the best many "black or white" medical doctors have.

It's got to be said that there's nothing new in what they're saying here - a number of (mostly European & British) psychiatrists have been saying this for a long time. Also, the DSM-IV criteria for depression are so notoriously broad that (in my experience) a lot of people just ignore them and only make a diagnosis of depression based on what they consider to be "real" clinical depression.

Here's another thing to think about: depression as a symptom.

I have recently been diagnosed with hypothyroidism and several nutritional deficiencies most of which have symptoms of depression. I wonder how many of the years I've been on antidepressants were really years that I was undiagnosed with hypothyroidism and nutritional deficiencies?

I feel like doctors are too quick to prescribe an antidepressant (which often have bothersome side effects) instead of looking to determine what is causing the depression, whether it be life situations or other medical conditions.

People tend to fall into one of two categories: either, they embrace the use of medication to treat psychiatric problems, or, they don't (often due to the belief that psychiatric problems are not "real"). It's ironic that both groups have trouble accepting the fact that, sometimes, people are just sad. Members of the first group are often scared that their problems might be self-induced or within their psychological willpower to fix, and members of the second group are often scared that their problems might be out of their own control.

I am glad that there are medications available to treat people with serious, debilitating and permanent biochemical imbalances. The problem is that medications are now being used to treat even minor "imbalances", and little emphasis is placed on lifestyle changes (diet, exercise, cognitive therapy). We have also neglected the rather serious (and occasionally long-lasting) impact that medications have; messing with the brain's biochemistry can cause medication withdrawal or other problems.

I believe that serious biochemical imbalances are real and require pharmacological treatment. I also believe that, as a society, we are losing the ability to make ourselves happy -- one of the most important skills we should all have learned after adolescence.

In terms of billions of annual dollars lost to the US economy associated with absenteeism resulting from MDD, one could argue about a surge in prevalence. And what of the unaccounted? Untold thousands of persons with undiagnosed MDD remain unaccounted because of cultural norms that recognize other venues for treating MDD- the last on the list are often mental health workers (second-to-last being the patient's GP). Without a handle on these numbers (cross-sectional or longitudinal)the authors' claims remain equivocal.