The age of depression

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

However, a major drawback of symptom-based criteria was that they eliminated the consideration of the context in which symptoms arose. One reason for the abandonment of context was the quest for reliability. Most depressions occur after some triggering event, so requiring that reactions be disproportionate to context would mean that clinicians would be frequently judging proportionality, substantially reducing reliability. (Never mind that increased reliability at the cost of validity and diagnostic logic is of no real value.) A second reason for leaving out context is that the DSM-III was supposed to be theory-neutral, which was interpreted to mean that it had to be neutral as to how the disorder was caused, although one could argue that distinguishing normal responses to events from disorders is not really a theory-laden distinction. Moreover, there was an impression that psychotropic medication worked on all depressions irrespective of the relation to triggering events, so that the "with versus without cause" distinction was considered irrelevant to treatment decisions. (However, even if medication sometimes works with normal reactions, the normality-versus-disorder distinction could have prognostic implications and thus could be an important consideration in whether or how aggressively to treat a condition.) Finally, there was a fear of misdiagnosing the truly disordered as normal, especially given that depressed patients are subject to suicide risk.

Granting some validity to these rationales, there does not seem to have been an organized attempt to balance potential harms from underdiagnosis and overdiagnosis, as is done with many medical tests. The problem remained that, as the previous 2,500 years of psychiatric diagnostic practice had attested, without an exploration of context and meaning, one simply cannot tell whether someone is likely suffering from intense normal sadness or a depressive disorder.

From sadness to depression

This brings us to how, in the case of depression, the DSM-III criteria went conceptually awry. (For brevity, we focus on "major depressive disorder" and ignore related diagnoses.) The DSM-III replaced DSM-II's vague criteria with specific symptomatic criteria. These criteria have remained more or less the same through the current DSM-IV, on which we focus.

Nearly all recent studies of depressive disorder are based on the DSM-IV's definition. Different specialists use this definition for different purposes: clinicians for diagnosing persons who have sought their help; epidemiologists for determining the number of people in the general population who are depressed; researchers for finding the causes of depression and for evaluating the effectiveness of treatments; economists for estimating the costs associated with depression; pharmaceutical companies for marketing their products; reimbursers for establishing medical necessity and determining quality-of-care standards; and mental-health advocates for quantifying how widespread this condition is. The DSM-IV definition is used not only in the United States but has also come to be the standard definition worldwide. The logic of DSM-IV's definition of depressive disorder is key to understanding depression as a social fact.