The age of depression

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

The definition requires that five symptoms out of the following nine must be present during a two-week period (the five must include either depressed mood or loss of interest and pleasure): (1) depressed mood; (2) diminished interest or pleasure in activities; (3) weight gain or loss or change in appetite; (4) insomnia or hypersomnia (excessive sleep); (5) psychomotor agitation or retardation (slowing down); (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive or inappropriate guilt; (8) diminished ability to think or concentrate or indecisiveness; and (9) recurrent thoughts of death or suicidal ideation or suicide attempt. In addition, to eliminate rare cases where symptoms are so mild as to be insignificant, symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Any person satisfying these criteria is today considered to have a depressive disorder, with three exceptions to be considered shortly. Yet, symptoms such as depressed mood, loss of interest in usual activities, insomnia, lessened appetite, and inability to concentrate might naturally occur for two weeks if a major loss or humiliation is experienced. Such reactions, even when quite intense due to the severity of the trigger, are surely part of normal human experience.

Two exceptions to the DSM-IV depression criteria simply shift the diagnosis to other categories of mood disorder--bipolar (manic-depressive) illness, or depression caused by a medication or a general medical condition. The third exception is the only acknowledgment of the existence of normal sadness--bereavement after the death of a loved one. Depression is diagnosed only when

   The symptoms are not better accounted for by Bereavement, i.e., after
   the loss of a loved one, the symptoms persist for longer than 2
   months or are characterized by marked functional impairment, morbid
   preoccupation with worthlessness, suicidal ideation, psychotic
   symptoms, or psychomotor retardation.

The bereavement exclusion thus allows that reactions of intense grief are not truly depressive disorders, unless the reaction lasts more than two months or it includes one out of a list of five especially serious symptoms.

The bereavement exclusion is notable for the limited range of normal grief reactions it allows. Surely grief reactions lasting more than two months are not necessarily disordered. And surely the five specified symptoms do not each necessarily indicate disorder: A normally bereaved individual may for two weeks experience "marked functional impairment" (such as not feeling up to usual work or social activities), may think that a lost partner was his or her "better half" and feel worthless or inadequate to life's tasks without him or her, or may entertain the notion that he or she might be better off "joining" the deceased partner, all without necessarily indicating disorder.

The most important thing, however, about the bereavement exclusion is that it offers exclusions only for reactions to the death of a loved one. Yet normal sadness reactions that are symptomatically similar to depressive disorders are not limited to bereavement. They encompass reactions to a wide range of negative events such as betrayal by romantic partners, being passed over for an anticipated promotion, failure to achieve long-anticipated goals, or discovering a life-threatening illness in oneself or a loved one. Of course, to qualify as normal responses that satisfy DSM-IV criteria, such reactions must involve a serious loss, and coping mechanisms must enable the individual to adapt to the new circumstances and get over the symptoms within a reasonable time after the precipitating event ends. If such a trajectory of adaptation does not occur, then one might infer that the original reaction had somehow caused an internal psychological dysfunction that now maintains a reaction that is no longer normal. But there are many intense reactions to loss that, just like normal bereavement responses, might satisfy DSM-IV symptom criteria but are not disorders.