The age of depression

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

The traditional distinction between abnormal depression "without cause" and normal depression "with cause" persisted into the twentieth century. In psychoanalytic discussions of depression, the former was called "melancholy" and the latter "mourning." In Freud's central article on depression, "Mourning and Melancholia," he asserted that symptoms associated with mourning, although intense, were a normal and self-healing condition that did not require medical treatment:

   Although grief involves grave departures from the normal attitude to
   life, it never occurs to us to regard it as a morbid condition and
   hand the mourner over to medical treatment. We rest assured that
   after a lapse of time it will be overcome, and we look upon any
   interference with it as inadvisable or even harmful.

Freud added an epicycle to the tradition. He observed that, although the symptoms of mourning and melancholia both include profound dejection, loss of interest in the outside world, inability to feel pleasure, and inhibition of activity, melancholia also frequently includes an extreme and inexplicable ("without cause") decline in self-esteem beyond the normal self-recriminations after a loss.

American psychiatry developed successive versions of its own classification system starting early in the twentieth century. Until quite recently, psychiatric definitions of depressive disorder continued to reflect the historical distinction between depression "with" and "without" cause. The first standardized classification system in the United States, the 1918 Statistical Manual for the Use of Hospitals for Mental Diseases, defines "reactive depression" much as Hippocrates did, to contrast it with normal sadness that arises in response to a great variety of losses:

   Here are to be classified those cases which show depression in
   reaction to obvious external causes which might naturally produce
   sadness, such as bereavement, sickness and financial and other
   worries. The reaction, of a more marked degree and of longer duration
   than normal sadness, may be looked upon as pathological.

The DSM-I (1952) and DSM-II (1968) that succeeded the Statistical Manual emphasized psychoanalytic concepts. The DSM-II defined "depressive neurosis" as follows: "This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession." In defining depressive disorders as "excessive" reactions, the DSM-II recognized that they are either disproportionate to actual loss or they involve no loss at all and result from internal causes (assumed to consist of internal conflict). Here, as in the 1918 hospital manual's definition, normal triggers beyond loss of a loved one were recognized, such as loss of a cherished possession.

For two and one-half millennia, psychiatry has held that normal human nature includes a propensity toward potentially intense sadness after certain kinds of losses. Disorder can be judged to exist, it has widely been agreed, only when explanations in terms of triggering events fail to establish a normal cause for the intensity or duration of symptoms.