The age of depression

Public Interest, Wntr, 2005 by Allan V. Horwitz, Jerome C. Wakefield

As the New York Times tells the story, Sherri Souza's husband is a National Guardsman posted in Iraq whose long-anticipated return home was canceled after the Pentagon unexpectedly extended his tour of duty. Like most spouses in this situation, Mrs. Souza is acutely disappointed. She misses her husband, worries about his safety, and is anxious for her family's future should he be killed or injured. When his scheduled e-mails are late, she becomes distressed and sometimes crawls into bed to await word of his safety. In the past, she might have described herself as very "sad," "lonely," or "worried." Now, however, she characterizes herself as "depressed." She is taking medication for her symptoms.

The characterization of our emotional reactions to life's challenges as "depression" is more than just a change in colloquial expression. It represents a transformation in psychiatric thinking. Psychiatrists are diagnosing more and more of the population as "depressed," by which they primarily mean the medical condition of major depressive disorder. Psychiatric epidemiological studies indicate that depression now afflicts about 10 percent of adults in the United States each year and about a quarter of the population at some point in their lives. This number has been steadily growing, they say: For the past several decades, each successive generation has reported more depressive disorders than the previous one. These enormous numbers have mobilized psychiatry, general medical practice, and the psychopharmacology industry to mount a coordinated (and profitable) offensive. Today, better recognition of unreported, hidden, or "sub-clinical" depression (that is, depression exhibiting fewer than the number of symptoms usually required for diagnosis) pushes prevalence numbers ever higher.

Not only the number of people said to be depressed but also the number actually treated has increased greatly in recent years. The percentage of the overall population in mental-health treatment for "mood disorders," the category of psychiatric disorder that includes major depression and related conditions, has nearly doubled since the early 1980s. Moreover, in 1997, fully 40 percent of all psychotherapy patients were diagnosed with some mood disorder, compared to 20 percent in 1987. Three times more people were treated for depression in primary medical care in 1997 than ten years earlier. The consumption of antidepressant medications both in absolute numbers and in percentage of diagnosed patients receiving medication has also dramatically expanded; persons treated for depression were four and one-half times more likely to receive psychotropic medication in 1997 than in 1987. At present, three of the seven highest-selling prescription drugs (Prozac, Paxil, and Zoloft) of any sort are antidepressants. W.H. Auden's "Age of Anxiety" appears to have been succeeded by our own "Age of Depressive Disorder."

No plausible theory of depressive disorder, whether genetic, psychological, or social, can explain why rates of depression would have increased so much in such a short period of time. Instead, the explanation appears to lie in changes in the ways that physicians, mental-health professionals, and people themselves characterize and diagnose their mental states. There are, and always have been, true depressive disorders, in which the response to loss goes awry and takes on a debilitating life of its own. But in the past, such disorders were distinguished from normal sadness that arises in response to life's vicissitudes. That traditional, common-sense distinction has broken down in contemporary psychiatry, resulting in the conflation of depressive disorders with normal sadness. The sources and social implications of this breakdown are as yet largely unappreciated.

A history of depression

How did this transformation of sadness into depression occur? To grasp the answer, the current approach to diagnosis must be placed in the historical context of 2,500 years of contrary medical and psychiatric practice. To follow this story to the present, one must also confront the esoterica of modern psychiatric classification as represented by successive editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorder (DSM-I through DSM-IV). Often called the "Bible of Psychiatry," the four incarnations of the DSM have offered official diagnostic definitions for all mental disorders.

As long as written records have been kept, Western cultures have recognized that depression can be a mental disorder. Hippocrates, writing in the fifth century B.C., provided the first known definition of the phenomenon as a distinct disorder: "If fear or distress last for a long time it is melancholia." While theories of depressive disorder have changed, the symptoms that indicate the disorder have not. For Hippocrates, its symptoms could include prolonged despondency, blue moods, detachment, nameless fears, irritability, restlessness, sleeplessness, aversion to food, and suicidal impulses, much like today's criteria. But Hippocrates's definition indicates not that such symptoms alone indicate disorder but that such symptoms over an abnormally long duration do.