The Great Depression

Is an epidemic of depressive disorder really sweeping America?

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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, 287 pages, $29.95

Is Tony Soprano really depressed?

That is one of many questions sure to hound readers of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder, a tightly reasoned, paradigm-shaking new book. Written by Allan Horwitz, a specialist in the sociological aspects of mental health at Rutgers University, and Jerome Wakefield, a professor in the School of Social Work at New York University, The Loss of Sadness could alter the official definition of depression, change the way we get mood-enhancing drugs, and clarify how effectively our culture delivers well-being.

In the late, lamented HBO series The Sopranos, mafia boss Tony Soprano's confessions to his psychiatrist opened a window on the fragile psyche of an extralegal executive. We discovered that Tony—a man who has killed with his bare hands—once dreamed a bird had absconded with his penis. More importantly, we learned that no man, no matter how tough, is impervious to depression.

There's no second-guessing his sadness, but does Tony really suffer from a genuine depressive illness, a breakdown of normal psychological functioning? And what about the rest of the Prozac-popping multitudes? Are they truly sick?

If the numbers are to be believed, serious depression is the dark lining in the silver cloud of capitalist abundance. "There is more purchasing power, more music, more education, more books, worldwide instant communication, and more entertainment than ever before," the psychologists Ed Diener and Martin Seligman wrote in 2004. "But contrary to the economic statistics," they continue, "all the statistics on depression and demoralization are getting worse." As Horwitz and Wakefield show, this claim is not clearly true.

According to epidemiological estimates, major depressive disorder afflicts 1 in 10 adult Americans each year. Outpatient treatment of depression in the United States increased 300 percent between 1987 and 1997, the last year for which comprehensive statistics are available. By 2020, according to the World Health Organization, depression will trail only heart disease as the leading cause of disability worldwide. As Seligman, a professor at the University of Pennsylvania, has written, "We are in the midst of an epidemic of depression, one with consequences that, through suicide, takes as many lives as the AIDS epidemic and is more widespread." What accounts for this deadly, rapidly spreading malaise?
Nothing.

According to Horwitz and Wakefield, "There are no obvious circumstances that would explain a recent upsurge in depressive disorder." The ranks of the depressed are bulging, they argue, because the clinical category fails to make the elementary distinction between normal, functional sadness and true mental disorder. The depression data are littered with false positives—jilted lovers, white-collar workers who missed out on a promotion, and kids nobody asked to the prom. People who are suffering but aren't sick.

The Loss of Sadness argues that Darwinian natural selection has equipped us with a "loss response" system. We are built to be saddened by loss, just as we are built to be enlivened by success. A genuine depressive illness requires the "harmful dysfunction" of the loss system. Even bouts of quite profound sadness—say, a month-long funk following a devastating romantic reversal—can be perfectly consistent with the proper function of our mental machinery. A response to loss of a duration or intensity out of proportion with the precipitating event often signals the breakdown of proper function; so do symptoms without an intelligible cause. Similarly, the failure of the fog to lift after well-motivated sadness has run its course could signal dysfunction, like a heart that hammers too long after a race. If you mourn your dead schnauzer for two weeks, you're probably normal. If you're still blue after two years, you have a problem.

Since its third edition was published in 1980, the Diagnostic and Statistical Manual (DSM), the standard handbook used by clinicians to classify mental problems, has defined major depressive disorder with a complex checklist of symptoms. In order to meet the exigencies of 15-minute doctor's visits and the needs of public health surveys, the few diagnostic qualifications calling for expert judgment were stripped away to produce a simple rule of categorization that family doctors, mental health epidemiologists, and even—or especially—computers can apply. To simplify only slightly, if you meet five of nine mundane requirements over the course of two weeks, you qualify as suffering from major depression. The checklist: a persistently low mood, a diminished interest or pleasure in almost everything, an increase or decrease in appetite leading to a gain or loss in weight, too much or too little sleep, fatigue or low energy, fidgetiness or listlessness, feelings of worthlessness or guilt, difficulty concentrating or indecisiveness, and thoughts of death, suicide, or an attempt of suicide.

The DSM admits a single exception: If the symptoms are precipitated by the death of a loved one, they represent normal grief and there is no disorder. But as Wakefield and his team showed in a 2007 study, one in four people diagnosed with major depressive disorder exhibited symptoms only negligibly different than that of the bereaved. They too were responding to major losses; it's just that the precipitating events were not deaths. In both sets of cases, the sadness came on the heels of a genuine loss, was similarly deep, and was similarly long-lasting. For Horwitz and Wakefield, it is the context within which symptoms present themselves, not just the fact that they exist, that divides sickness from health. A woman who awakes one day to find herself bereft of hope and a woman who has lost her job may have identical symptoms, but that does not mean they are both ill.

According to Horwitz and Wakefield, the definition of depression in the DSM is an embarrassing overreaction to some prior embarrassments in the psychiatric profession. A widely-touted 1972 study, for example, exposed a scandalous degree of disagreement between British and American shrinks in the diagnosis of depression in the same patients. The third edition of the DSM was a comprehensive revamp, headed by the prominent psychiatrist Robert L. Spitzer, aimed at improving the reliability of diagnosis across clinicians by laying out clear, symptom-based diagnostic rules that take no sides in psychiatry's contentious debates about the root causes of pathologies. On that level Spitzer succeeded, vastly increasing the chances two doctors given the same clinical information would agree on a depression diagnosis. But it came at the cost of gutting the validity of the diagnostic rule; that is, its ability to sort the truly sick from the merely beleaguered.

Spitzer, who contributes a preface to The Loss of Sadness, reflects prevailing psychiatric opinion when he registers skepticism about the clinical utility of the context-sensitive diagnostic approach Horwitz and Wakefield defend. Spitzer implies that hordes of false positives are better than a few false negatives. It is true, as Spitzer worries, that a more scientifically valid diagnostic category could allow a few truly depressed people to slip undetected through the diagnostic net. But such an outcome does not vindicate bad science. Instead, it should draw our attention to the careless, checklist-centered diagnostic practice encouraged by the over-wide definition of depression.

Patients seeking help from a doctor deserve an accurate diagnosis, appropriate treatment, and a prognosis they can count on. A new self-image as "mentally disordered" and a vial of antidepressants (beware sexual side effects!) might not always work wonders for those feeling temporarily bleak. Then again, mood-enhancing drugs may well help many of those struggling through normal loss. But couldn't a tighter diagnostic rule put drugs out of reach for many people who want them? If we need to revise our definition of depression, don't we also need to accept the right of everyone, sick or not, to feel the way they want?

Horwitz and Wakefield don't want anyone to lose access to their pills, but they are weak on this score, arguing that if a patient who is not ill really is helped by drugs, doctors will nevertheless write prescriptions and fool the insurance companies. In the meantime, they can only hope that their proposed diagnostic reforms will help "facilitate a discussion" about allowing those who are not certifiably ill to receive drugs anyway. That discussion may not conclude as they wish, given that so many Americans believe drugs should be reserved for those officially designated "sick."

Nevertheless, we've come a long way in dissociating sadness, whether normal or disordered, from a lack of inner fortitude. The overbroad definition of major depressive disorder in the DSM, together with the 1987 appearance of Prozac, seems to have done much of that work. Thanks in large part to pharmaceutical companies trying to sell us (and our insurers) on the idea that every bout of the blahs is a treatable medical disorder, more Americans than ever attribute depressive symptoms to a "chemical imbalance," seek treatment, and approach their pharmacists with prescription slips signed by insurance-reimbursed physicians.

But we should not expect a swift correction in the way depressive disorder is diagnosed, no matter how strong Horwitz and Wakefield's case is. As they make clear, thousands of mental health studies, thousands of careers, and tens of millions in research funding are wrapped up in the very diagnostic category they claim is fundamentally broken. Doctors who are paid by insurance companies have an interest in keeping the category permissive. So do pharmaceutical companies wanting to boost sales of mood enhancers. And so do the ordinary people who feel better on Prozac, Wellbutrin, or Effexor, whether or not they genuinely qualify as disordered.

The evidence suggests that anti-depressants work just as well as, and are cheaper and less time intensive than, cognitive behavioral therapy. Drug marketing seems to work as well: Advertising can increase demand when people were previously unaware a product was available. So the hugely increased diagnosis of depression and the correspondingly huge increase in the use of mood-enhancing drugs may be a sign of improvement in the way we feel. As the health economists David M. Cutler and Elizabeth Richardson Vigdor write in a paper published by the Brookings Institution, "Only measuring the prevalence of reported depression over time leads to the conclusion that the prevalence of debilitating mental illness has increased, when in fact the opposite may have occurred." If anti-depressants generally do make people feel better, an increase in usage should mean a decrease in sadness. Promiscuous diagnosis may be a boon for the national mood.

Interestingly, the evidence for an increase in normal sadness is also scarce. Data on "happiness" or "life satisfaction" from the huge General Social Survey flatly contradict the depression data. The percentage of Americans reporting themselves in the lowest category of life satisfaction dropped slightly over the past 30 years, just as rates of diagnosed depression were exploding. We should expect an epic epidemic of sadness, not to say depressive illness, to at least register in the life satisfaction numbers.

And if depression is booming, why do the suicide trends look so rosy? According to data from the U.S. National Center for Health Care Statistics, the overall suicide rate in 2003, the last year recorded in the U.S. Statistical Abstract, was barely higher than the rate in 2000—which was lower than that of any of the previous 50 years. Suicide among teen boys did hit a record high in 1990, but rates have declined sharply since then, perhaps because of the increased availability of antidepressants.

Indeed, last year a group of UCLA medical researchers found a strong statistical association between the decline in the suicide rate and the growth in the number of people taking fluoxetine (generic Prozac) during the 1990s. (A team at Stanford has proposed an alternate cause for the decline: "the sustained economic recovery of the 1990s.")

The alleged epidemic of depression simply doesn't exist. Horwitz and Wakefield are right: Millions who have been diagnosed with major depression never had it in the first place, even if their lives were nonetheless improved by the drugs they were prescribed. We risk our very real and very satisfying prosperity if the self-assigned stewards of public health insist on "treating" our illusory unease. That would be depressing.

Will Wilkinson is a policy analyst at the Cato Institute and the author of the Cato study, "In Pursuit of Happiness Research: Is It Reliable? What Does It Imply for Policy?"

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  1. His skepticism makes me sad.

  2. The suicide rate (corrected for ethnic group) provides us with the only objective measure of depression. All other forms of diagnosis are purely subjective and are subject to distortion from fads or economic pressures. By this measure, depression has not increased significantly.

    I think however, that depression today maybe a more unpleasant experience than in the past. More people today live an atomized existence with relatively weak ties to family and intimate community. Such isolation magnifies the effects of normal depression. Age stratification of social peers cuts people off from the advice of greybeards who have seen bad times come and go and who can provide valuable perspective.

    When people experience the blues, they find themselves alone. Friends and colleagues don’t have the same obligation as family and community to hang around when things turn ugly. Drugs and therapy provide substitutes for traditional support networks.

  3. Is this really just a symptom of the boomer generation aging? As people age, their friends and family die, leaving them depressed. Many boomers experienced a lot of their joy in life doing travel and sports that just isn’t possible for a majority of people after they are over the hill.

    I’m no psychiatrist, but I predict that this “epidemic” will become worse before it gets better with the boomer die off in 15 to 20 years.

  4. Aren’t those statistics on suicide a little wrong? IIRC, there was recently a release of some numbers concerning suicide that actually showed a pretty substantial rise amongst young people. I might be wrong on that, though…

    Either way, as someone who ‘really’ has depression and who sees an actual psychiatrist and not just a general doctor, I take issue with some of the other assertions. No doubt depression is diagnosed incorrectly in some cases, but I know from personal experience that I had debilitating ‘blues’ for several months with no apparent trigger. It’s taken over a year now for me to even get back close to normal, and that’s with help from cognitive behavioral work and medication.

    When the writer points to people being depressed over the death of a loved one, depending on how severe they’ve taken the death, maybe they really *do* need some medication temporarily. I don’t mean for 6 months, but if they can’t function normally to work or study, they may need something. It’d be better to take antidepressants for three weeks to a month (and, in addition, work on cognitive behavioral exercises and/or spend time with close friends/family) and keep your job than to be unfocused and depressed, then lose your job, imo.

    When I was in school, half my first grade class was hopped up on ritalin. It was sad to see little kids like that, so I’m not defending over-medicating people, but I am saying that, when it comes to depression, maybe we should be better safe than sorry? People should be carefully screened before they get anti-depressants, or in my case mood stabilizers, because there can be some very dangerous side effects if the doctor isn’t paying attention to the patient. But that goes for any drug that can have severe side effects.

    So yeah, no doubt that depression is over-diagnosed, but I still think it’s better to be safe than sorry. And it is a little ironic that a group of people who support drug legalization (I am one of them) are likely going to comment this article and attack anti-depressants.

    .o2

  5. I’ve been depressed in the past. I, like most people self medicated and sought advice (therapy?) from non professionals whose opinions I respected. Drugs make you feel better as you “get over it” and sage advice helps in putting it all in perspective.

    I’m not denying that persistent depression is real medical problem, but the danger of over diagnosis is real.

    BTW, in a rational society, Prozac would be available over the counter. Y’all knew that, I suspect.

  6. Actually, we do pretty well with depression compared to Europe and East Asia. The highest suicide rates are found in Scandinavia and Japan.

    Funny, they probably have the worlds highest standard of living, low crime, and incorruptible governments but are also the most depressed places in the world

  7. Funny, they probably have the worlds highest standard of living, low crime, and incorruptible governments but are also the most depressed places in the world

    Did you know that the first Matrix was designed to be a perfect human world? Where none suffered, where everyone would be happy. It was a disaster. No one would accept the program. Entire crops were lost. Some believed we lacked the programming language to describe your perfect world. But I believe that, as a species, human beings define their reality through suffering and misery. The perfect world was a dream that your primitive cerebrum kept trying to wake up from. Which is why the Matrix was redesigned to this: the peak of your civilization.

  8. Did you know that the first Matrix was designed to be a perfect human world?

    Are you telling me I can dodge bullets?

  9. This is where I crank “How Soon Is Now?”

  10. No, Neo. I’m trying to tell you that when you’re ready, you won’t have to.

  11. And if depression is booming, why do the suicide trends look so rosy? According to data from the U.S. National Center for Health Care Statistics, the overall suicide rate in 2003, the last year recorded in the U.S. Statistical Abstract, was barely higher than the rate in 2000-which was lower than that of any of the previous 50 years. Suicide among teen boys did hit a record high in 1990, but rates have declined sharply since then, perhaps because of the increased availability of antidepressants.

    It sure does seem like he answers his own question there.

  12. Uh, since when did an increase in the diagnosis of a psychological disorder mean that there was an epidemic? What ever happened to “previous underdiagnosed” as a possibility, and in fact a certainty in this case? Also, how did Wilkinson miss the word “persistently” in the DSM? If you’ve got those symptoms for months after your spouse dies or your goldfish gets fin rot, that’s probably not “persistently”. If you’ve had those symptoms since puberty and you’re 25 years old, that’s “persistently”.

    This sounds like more of the “don’t use SSRIs as a crutch” school that pops up here every now and then. While I’m sure that there’s someone out there on an SSRI who doesn’t need it, my experience is that there are exponentially more people who are clinically depressed who don’t seek treatment because they don’t want the stigma or they don’t want to get caught up in the “agenda of the depression epidemic” or whatever the buzzphrase of the day is.

    Here’s a tidbit for you: Taking SSRIs (or other antidepressants) when you don’t need them has unpleasant and obvious side-effects like inability to orgasm and persistent sleepiness. It’s not like its a scam to sell useless drugs or bogus therapy services. That’s what Scientology is for.

  13. Rimfax,

    Agreed. I also find it interesting that Reason is pro-mind altering when it comes to recreational drugs, but anti-mind altering when it comes to clinically tested pharmaceuticals.

  14. Uh, since when did an increase in the diagnosis of a psychological disorder mean that there was an epidemic?

    Because hyperbole is a great first step to starting new programs.

    Can anyone smell “War on Depression” coming?

  15. The infection of every nearby thread with Morrissey references depresses me.

    This is where I crank “How Soon Is Now?”

    You have already waited too long.

  16. I also find it interesting that Reason is pro-mind altering when it comes to recreational drugs, but anti-mind altering when it comes to clinically tested pharmaceuticals.

    That seems to be an unfair characterization of Reason staffers’ opinions, based on many articles I have read.

    I personally only worry about pharmaceuticals in so far as I fear some government stooge 10 years from now might try to force me to take anti-depressants. With all the shit the government is pulling right now, I don’t know how 90% of the U.S. isn’t depressed.

    If you think this sounds crazy, just remember, they force feed us fluoride.

  17. I also find it interesting that Reason is pro-mind altering when it comes to recreational drugs, but anti-mind altering when it comes to clinically tested pharmaceuticals.

    And pro-free markets, but anti-farmers’ markets.

    It’s really laughable.

  18. Rimfax & John-David,

    I went out of my way to emphasize, repeatedly, that one should be able to take mood enhancers whether or not one is really ill. Did you read to the end?

    Not to be defensive or anything.

  19. Will,

    Yes, and my criticism wasn’t solely based on your article. I’ve just noticed a persistent anti-psychiatry bias in this magazine, which is odd considering the stance on such things as medical marijuana.

    And I am totally against governments forcibly altering people’s moods. I am just as vehement against anyone forcibly preventing one from altering their mood, or seeking help from a physician to do so. I would think Reason would accept that logic.

  20. If I can offer an analogy.

    Fever is a natural and desirable response to certain infections. At low levels it helps more than it hurts. If it runs to high then it can kill.

    Depression functions the same way. Depression allows us to more objectively assess our action following a negative event. However, just like fever, if it runs to extremes or activates without a negative event it becomes a disease process.

  21. Funny, they probably have the worlds highest standard of living, low crime, and incorruptible governments but are also the most depressed places in the world.

    I think Greg Easterbrook called this the “Prosperity Paradox”, the idea that the better and more prosperous our societies are becoming, the less happy we seem to be collectively. It seems completely counterintuitive, but there really appears to be something to it.

  22. John-David,

    I’ve just noticed a persistent anti-psychiatry bias in this magazine, which is odd considering the stance on such things as medical marijuana.

    I think if you read closely you will see that the anti-psychiatric bias at Reason springs largely from resentment at authority that psychiatrist claim based shoddy or non-existant science. The article under discussion, for example, ask whether social, political or economic forces have caused psychiatrist to define a normal and healthy variation in mental states as a disease.

    Given the lack of objective standards in the mental health field, its always a fair question to ask.

    From an ideological viewpoint, remember that psychiatrist, like all doctors, work within a State mandated guild/cartel. Existing psychiatrist decide who can and cannot become a psychiatrist and what diagnosis and treatments are legitimate. They exert significant and largely unmoderated power over the rest of us even if we don’t patronize them directly.

    Everyone should view such an arraignment with caution.

  23. Shannon,

    Good points. I think the main problem is that there is no objective diagnostic method for determining mental disorders, which can cause people who are merely going through a bad stretch in life to be treated the same as people who have serious brain chemistry issues. Hopefully the day will come when there is some sort of MRI that can show how the brain interacts with the various neurotransmitters.

    Of course, then we’ll have the scare articles about people being forcibly examined and treated.

  24. John-David,

    I agree, Objective diagnosis will solve most of the problems we now see in the mental health field.

    Mental health right now is on about the same objective footing as conventional medicine was a century ago. They kind of have an idea what they’re looking at but they lack the day-to-day clinical tools to really nail things down.

  25. Depression is a fine mistress.

  26. I imagine Jesus was pretty depressed when the Romans nailed him to the cross. Then he got over it.

  27. Conventional medicine is pretty ad hoc too. No one know what causes cluster headaches, but we’ve developed fairly effective treatments to cope with them.

    There is a lot of “If it looks like it works and it feels like works, then it works” in conventional medicine.

  28. de stijl,

    That’s why SSRIs are so popular. Nobody know for sure how they work, but damn they work.

  29. Once again I will assert that Reason Magazine is a propaganda organ for the pharmaceutical industry. Most antidepressants are no more effective than placebos. Also, there is absolutely ZERO evidence that mental illness is caused by a biological abnormality. They have no idea why people are depressed, and the drugs’ action in the brain does nothing but act as the chemical equivalent of a lobotomy. Psychiatric drugs are poisons designed to make patients more sick, both physically and emotionally.

    Psychiatry is a scam. The industry is a direct predecessor of the CIA’s MK-ULTRA mind control experiments. Honestly, do you really think they are incapable of making a drug that doesn’t make you impotent?

  30. Also, has anyone considered that more people are becoming depressed because there is more to be depressed about? There is an absolutely insane war going on with no end in sight. Our elections are rigged. The food we eat is doused in poisonous herbicides. The domestic fascist police state marches on unimpeded. If you don’t get depressed from watching television, you must already have a lobotomy.

    Also, look at who funds the Reason Foundation and you will notice almost every major pharmaceutical company is on the list.

  31. you know who

    Uncle Bill?
    Jody?
    Buffy?
    Mr. French?
    Mrs. Beasley?
    Chief?

    McCloud!

  32. I’ve just noticed a persistent anti-psychiatry bias in this magazine

    Bullshit. This magazine swallows their propaganda hook, line, and sinker. They still haven’t reported on Zyprexa, which is an antipsychotic drug that causes diabetes. We now know that Eli Lily is aware of this and yet still continues to market it for every possible off-label use. This is reaching tobacco industry proportions, so why isn’t Reason… Oh wait, I forgot they are shills for the tobacco industry too!

  33. you know who

    Tom Cruise?

  34. Will Wilkinson,

    I’m gonna give it another closer read. My reaction was certainly colored by previous related articles here, so I’ll wipe the brown-color off my glasses and give it a reread tonight. Thanks for your response, defensive or not.

  35. That’s why SSRIs are so popular. Nobody know for sure how they work, but damn they work.

    Actually, they’re fairly well understood as psychiatric drugs go. They inhibit the reputake of serotonin from the synaptic cleft, which results in higher concentration, which results in higher serotonin to receptor ratios on the post-synaptic side via the downregulation of the number of receptors as well as the raised concentration. The subjective effects of SSRIs and other drugs that act on serotonin concentrations suggests that serotonin signaling is used in regulating mood, with stronger signals being related to a more positive and active mood.

    However, one should not jump to the conclusion that mood can be reduced to serotonin concentrations – drugs targeting the dopamine and norepinephrine concentrations also show antidepressant activity, although they’re somewhat less understood, and the efficacy of different drugs with different patients may indicate more than one underlying pathology.

  36. For further reading, you might try Ray Moynihan and Alan Cassels’ Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients

  37. Regarding the contention of the article that depression is overdiagnosed, I think the actual incidence of depression has probably remained fairly stable (that susceptability is somewhat heritable lends some support to this supposition) and that we actually went from underdiagnosis to overdiagnosis. In addition to the broadening of the diagnosis, the social stigma associated with depression and psychiatric meds has decreased while the quality of the treatments has increased (particularly with regard to the negative side effects of meds – tricyclics and MAOIs are no fun), making people who suspect they have depression more likely to seek treatment.

    I think that while context may be underappreciated in diagnosising, it isn’t going to allow you to draw a clear line. Episodes of clinical depression may lack a clear trigger, but it is often the case that they’re triggered by the same sort of events that would make a “normal” person sad but the resulting sadness is exceptional in its duration and intensity.

    Additionally, part of what may be driving overdiagnosis currently is defensive diagnoses – if someone presents with symptoms that fall in the grey area (and it’s a pretty broad grey area) and isn’t dxed then commits suicide, the doctor may be opened up to malpractice liability for it. The milder side effect profiles of the more recent drugs also decease the disincentives to overprescribing.

  38. tricyclics and MAOIs are no fun

    True, for the most part. Parnate triggered full-blown bipolar cycling for me (which had never happened before). However, Selegiline was the best antidepressant I ever tried (and I’ve been on lots of them). At lower doses, it only inhibits MAO-B, so there aren’t the same extreme dietary restrictions as the other MAOIs. I had to stop taking it because it was making me so scatterbrained that I couldn’t concentrate at work. I’ve done a bunch of digging, and I haven’t read any anecdotes of other people having the same problem though.

  39. “The evidence suggests that anti-depressants work just as well as, and are cheaper and less time intensive than, cognitive behavioral therapy. ”

    As a psychology student who has read the research on this topic, that statement is factually incorrect. The combination of drugs and therapy is the best, followed by cognitive behavioral therapy, and lastly medication alone.

    Also, just because someone’s symptoms are sub-clinical, that does not mean they are imaginary or that they are able to deal with them on their own.

    As had been pointed out before, I find it hard to believe that two respected psychologists would miss the “persistent” part of the major depressive episode diagnosis. Without a diagnosis of a Major Depressive Episode, the only other option is Disthymia, which is persistently negative mood having persisted for no less than 2 years.

    Either two respected doctors screwed up some pretty basic diagnostic criteria, or this author extrapolated outward too far. The idea that mental illness is in fact an “illness” has made it more okay to seek treatment; however, it has also lead to an increased depersonalization and decontextualization of the practice. Context is indeed paramount in psychotherapy and there are few clinicians who could, in good conscience, stick solely to the criteria in the DSM.

    By the way, we’re on DSM-IV, not III.

  40. I wonder the depression “epidemic” isn’t a symptom of the self-esteem culture that invaded our public school system. Students are taught to believe that
    – they’re great!
    – they can do anything!!
    – whatever they think is right is right!!!

    Then they get out in the real world and they discover that, irrespective of their personal desires, 2+2 does not equal 7. They find out that being functionally illiterate is not a qualification for most CEO jobs. They find out that their boss actually expects them to do their job. They find out that a mastery of computer games doesn’t necessarily translate into a high paying job.

    So, they’re unhappy. Rather than admit that they’ve made a mess of their lives, and that their lives will remain a mess unless they undertake some drastic measures, they become a victim of depression. Give me a pill and make me happy.

    Don’t get me wrong, there are people do suffer from clinical depression. I just think a lot of the pill poppers want an excuse to be an underachiever and victimhood is an easy road to take.

  41. Taktix, it’s only because they’re after your precious bodily fluids.

  42. “According to Horwitz and Wakefield, “There are no obvious circumstances that would explain a recent upsurge in depressive disorder.”

    So the near complete breakdown of every good thing our country once stood for isn’t a reason for sadness? The loss of human rights, the deteriorating middle class, our failing educational system, the frailty of modern marriage, and no confidence in our government isn’t sufficient cause for a gloomy outlook on life? Maybe I just need a prescription, but I can’t afford it.

  43. Going way out into left field, it could be that the unprecedented mixing of genetic backgrounds that has taken place since WWII in this country might have something to do with it. I’m the mutt son of a mutt mother, and she, like me and at least one of my siblings, deals with bipolar disorder and anxiety on a constant basis. Fortunately for me, and unfortunately for them, I have health insurance.

  44. Will Wilkinson,

    I apologize. I skimmed aggressively and relearned why I hate to skim. You really do cover most all of the points that I chided you for. I agree that the DSM criteria of “two weeks” is ridiculously short.

    I could try to defend it on the grounds that most people cannot remember their past moods accurately, so the past two weeks is really the best that a clinician can hope for with any accuracy. However, that should be left for clinician interview techniques. They should still endeavor to obtain enough information to suggest a much longer period of unexplained or disproportionate depressed mood.

    I’m still inclined to think that depression is far more underreported and underdiagnosed than it is overdiagnosed, but as someone who has been very effectively treated for persistent depression, I find that my acquaintances are disproportionately people who have suffered from persistent depression.

  45. John-David,

    Your mutt theory resonates with me, as well. As printed in Reason, black Americans are suffering from heart disease problems that do not affect Africans. It seems that the European genes that most(?) black Americans have inherited are interacting with African genes to cause early heart disease.

    It doesn’t seem like much of a stretch that some similar unfortunate mixes could be causing neurochemistry problems. I’ve often theorized that they could be accounting for the metabolic problems that many Americans suffer from. But it could also be that the corn that helps American kids (and cows) grow like holy hell, isn’t so great for adult metabolisms.

    As mutts, we are also undoubtedly the beneficiaries of some very fortunate genetic mixes, as well.

  46. As a society hooked on crap food and believing that their nirvana keeps existing without any impact on the rest of the world, its not surprising you get depressed when you start finding out whats really been going on.

    Its not psychology its the apathy when/if you vote

  47. you know who,

    Nice observation! I get pretty depressed too when I watch television…or when I realize the meat I eat comes from a factory farm where they legally abuse the poor animals…or when my young generation is too obsessed with their facebook and myspace account to care about what is going on around them…who wouldn’t be depressed. Only a little reform, revolution, and meditation is needed to remedy the problem.

  48. The way I understand Will’s review, it’s mostly an attack on the idea that depression rates are up and therefore obviously we should forget about about economic growth and realize that really everything is going down the tubes. This idea has been widespread lately and it’s mostly wrong and confuses the issues. And if that’s the idea that Will is trying to refute, then I fully agree with him. It is not uncommon for the perceived rates of any problem, medical or otherwise, to go up when a solution (in this case SSRIs) becomes available — but this is a good thing, not bad, for it mainly shows that the solution is apparently working.

    Will could, of course, have been a little more careful in his writing; especially the allusions to depression being like sadness but more so are inaccurate given that the severely depressed often report being unable to feel any strong emotions (“flatness of affect” I believe this is called), sadness included.

    But I take issue with a lot the commenters here.

    First of all, you insult crutches. Don’t do that. Crutches are among the most sensitively minded of medical devices and you should not hurt their feelings.

    Jokes aside, it is entirely irrelevant whether or not depression is a “medical” problem or a problem otherwise, nor whether antidepressants cure it permanently or temporarily or even just suppress symptoms (what do you care ‘long as it works?), nor should mental problems require any Good Machismo Mixed With Puritanism Seal Of Approval. It’s a problem that can sometimes be solved or at least alleviated rather simply. Fluoxetine is not the be-all and end-all of depression therapy but it does work, especially when combined with therapy, and it is comparatively cheap, and it can reduce the suicide rate. It is not up to anyone to tell anyone else not to try and peacefully use what they think is the most effective way of solving their mental problems.

    The DSM criteria seem a little silly at times, but the main problem with the DSM is not the DSM but those who overstimate its meaning. It is called Diagnostic and Statistic manual for a reason: the drafters actually openly recognize that much of what they are doing is establishing arbitrary categories of mental disorder, possibly imperfect, in order that various researchers may gather statistics and otherwise do research and be on the same page about definitions. Their definitions of depressive disorders allow you to start trying to establish to what extent a diagnosis of major/minor unipolar/bipolar etc. depressive disorder is predictive of e.g. subsequent suicide, and if you’re going to do that kind of research you need a wide range of definition ranging from “feeling a bit off” to “patient would commit suicide if s/he could be bothered to get out of bed.”

    Also, there is another real tradeoff in these criteria even if you really wanted to use them to do diagnosis and treatment blindly. Many people who could really use psychological help — and again, by “could really use” I mean, in at least some cases, “would end up killing themselves without it” — are reluctant to get help and likely to understate their problems. Some commenters seem to have an impression of mental patients as insufferable whiners using their purported illness as an excuse for attracting attention and unlimited happy pills: just consider it possible that this is simply because for obvious reasons you do not notice the ones that keep their problems to themselves and feel (overly, unreasonably) bad about bothering friends, relatives or professionals with them. It makes sense to give actual working mental health pros a bit of leeway in diagnosing people that they damn well know, intuitively (!), could use some help, but who are too self-conscious to shower said shrinks with the long lists of embarrassing symptoms that might be required for a diagnosis following stricter criteria.

  49. >Funny, they probably have the worlds highest standard of living, low crime, and incorruptible governments but are also the most depressed places in the world.

    >I think Greg Easterbrook called this the “Prosperity Paradox”, the idea that the better and more prosperous our societies are becoming, the less happy we seem to be collectively. It seems completely counterintuitive, but there really appears to be something to it.

    Maybe there’s also a correlation between prosperity and the breaking down of tight communal connections. The poorer the country, the larger the family unit, it can extend all the way to the clan or cast. That might be one factor contributing to the high suicide rates in Scandinavia. Even the poorest Scandinavians won’t starve, end up in the streets or die of treatable infections, but emotionally a good deal of people are in complete isolation, especially the elderly.
    I might even argue, that if you have to fight for your survival your mind just doesn’t get so many opportunities to get tuned to the depressive mode. But still I absolutely abhore an ideology, which calls a communaly constructed safety net stealing. No wealthy civilized country should in my opinion, in fear of supporting free riders, shrink from such an elementary responsability any more than it should, in fear of letting some criminals off the hook, forsake the idea of a fair trial. The big dilemma is though, that all morally right decisions society wise won’t necessarily lead to greater mental well being. The hunter gatherers who used to leave the old and the sick in the wildernes to die probably had next to no problems with depression.

  50. Do not overlook the fact that there are other advantages to being deemed depressed besided access to drugs that make you feel good.

    Under federal law, any psychological condition recognized by the DSM is considered to be a “disability” under the Americans with Disabilities Act and the Family and Medical Leave Act — thereby entitling the employee diagnosed as depressed with a battery of legal rights and protections, including the right to be “accommodated,” the right to have up to twelve weeks off from work per year without penalty, etc.

    Also, plaintiffs who claim that the defendants caused them to become depressed can recover additional damages, the estimated cost of future psychological treatment, etc.

    With incentives like thses, is it any wonder why the number of people claiming depression has risen?

  51. @Wicks:

    The way to deal with that is to change the ADA, not the DSM. If the government chooses to grant exaggerated privileges based on some diagnosis, that’s the government’s business – but if I were in mental healthcare I would absolutely refused to let that influence my job, which would be to help my patients and not to minimize the impact of some politician’s bad law.

  52. That might be one factor contributing to the high suicide rates in Scandinavia.

    Actually it’s attributed to lower levels of sunlight.

    As for the Japanese, sucide has had a history of cultural acceptance.

  53. … and I forgot to add, concerning the social isolation idea, I recall reading that suicide rates were lower in southern Europe than in the rest of Europe. They’d concluded it was due to stronger family ties.

  54. extralegal executive

    Ooo. That’s a good one.

    if a patient who is not ill really is helped by drugs, doctors will nevertheless write prescriptions and fool the insurance companies.

    But they won’t fool the DEA.

    Funny, they probably have the worlds highest standard of living, low crime, and incorruptible governments but are also the most depressed places in the world

    They also have some of the most intrusive “hammer down the nail that sticks up” governments in the civilized world.

  55. Scandanavians have to live through a long dark cold winter. Probably pretty isloated. Plus they have to eat lutfisk,

    Japanese have really rigid expectations for adults, and I think, a history of regarding suicide as an acceptable way out (sepeku/hara kiri).

  56. If you’re looking for a great resource of essays have a look at: Assignment writing service

  57. I think the world is on the edge of another ‘Great Depression’

  58. Faktisk, er den over-diagnose av depresjon faktisk et problem. Men folk tror underlige er at en gruppe mennesker som st?tter legalisering av narkotika.
    Det vi trenger er ? sakte lede dem tilbake til gruppen, slik at grupper som mottar dem. Snarere enn ? bruke medisiner for ? kontrollere det med disse stoffene noen forskjell.

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