Thursday, April 08, 2010

Book Review: The End of Sadness

Why are so many people in this country seemingly suffering from depression and why are anti-depressants one of the biggest selling drugs? The answer, according to the authors of The Loss of Sadness is that the definition of depression has been set in such a way that many more people than should will be diagnosed as suffering from depression. What's so bad about that? For one, people will be medicated who are not suffering from depression but appropriately responding to a life circumstance, like the loss of a job or the breakup of a romantic relationship. The problem is that reaction to these life events will express the same symptoms as those delineated in the latest version of the mental health diagnostic manual, the DSM. Second, a false measure on the true extent of depression will shift resources to where they are not truly needed. Third, there is the philosophical issue, not directly addressed by the authors, of what persistent medicalization against life's unwanted but unavoidable circumstances does to us as human beings.

Authors Wakefield and Horwitz show how normal sadness was always understood as a natural response to certain types of life events, and that abnormal responses were always differentiated as such. The latter was seen as a type of condition that was without context or out of proportion to the event in question. The effort to focus on symptoms at the exclusion of context was partly driven by the mental health profession's desire to systematize diagnosis, thereby making it more likely that psychiatrists or general practitioners would arrive at the same diagnosis given the same symptoms. Unfortunately the human mind is not so submissive to external labeling, and this cookie cutter approach was bound to identify a great number of false negatives. This Wakefield and Horwitz show as they expose the biased results of community surveys, particularly those of adolescents, whose lives and mindsets can fluctuate in mood almost daily, depending on where they are on the "cool" scale.

Now that so-called Big Pharma is a major player in the Name the Disease Game, it seems virtually impossible that the mental health profession will reverse on this issue. Nevertheless, as the next version of the DSM is revised (due out in 2011), Wakefield and Horwitz urge their mental health colleagues to consider reuniting context with symptoms so as to revive the traditional distinction between normal sadness and true depression.

This is a great read on the history of how depression came to be defined the way it is today. In particular, it sheds light on how the wrong premises can lead to faulty conclusions and to misguided public policy. In how many other fields could this exist?

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