by Allan V. Horwitz and Jerome C. Wakefield; New York, Oxford University Press, 2007, 312 pages, $29.95
Dr. Quasem is a child and adolescent psychiatry fellow and Dr. Chrisman is training director of the child and adolescent psychiatry fellowship at Duke University Medical Center, Durham, North Carolina.
The book The Loss of Sadness by Allan Horwitz and Jerome Wakefield is a critique of the current criteria for the diagnosis of depressive disorder with a description of how the diagnosis of depression has evolved over 2,500 years. The authors have combined their work to analyze how psychiatry began diagnosing depressive disorders on the basis of symptoms without considering the contextual basis of sadness—except for bereavement, which is a contextual factor that is included in the DSM criteria. They argue that this change has resulted in large overestimates or "false positives" in the numbers of people diagnosed as having a depressive disorder.
The DSM definition of a mental disorder specifies that a disorder must involve a dysfunction within the individual and must not be an expectable response to a stressor. However, the authors argue that because the individual diagnostic sets in the DSM do not include this specifier about the stressor, the distinction has largely been left out of practice and research. Now that the recent explosion of research in neuroscience, epidemiology, and genetics has led to a reevaluation of the diagnostic classification system, this highlighting of the significant weaknesses of the current symptom-based criteria is timely.
The authors' description of the evolution of the diagnosis of depression culminates in the publication of DSM-III, when the diagnosis was changed to symptom-based criteria. The authors discuss the implications of such inclusive diagnostic criteria for depressive disorders, which have likely contributed to the apparent epidemic of depression as evidenced by the World Health Organization's claim that depression is a leading cause of worldwide disability. Issues related to research, public policy regarding widespread screening, prescription of antidepressant medication, and pathologizing the normal feeling of sadness are discussed in detail. The authors also critique the reasons why diagnostic criteria have not been changed. A major objection to suggested changes is a possible denial of professional treatment to many in need of assistance. The authors contend that treatment should not be denied to anyone who needs it but that clinicians should be more clear about what they are treating and not confuse normal, although painful, reactions with true disorders.
Finally, the authors offer some solutions about how to solve the validity problem of diagnosing depression. These solutions include expansion of the bereavement exclusion in DSM to include other major life stressors, self-administered questionnaires with more explicit questions about the onset and context of symptoms after stressful events, and standardized or contextual scales that relate the degree of stressfulness in people's lives to their degree of depressive symptomatology.
The Loss of Sadness is a useful and interesting review of the history of depression and its diagnosis over time. Cultural and societal influences on what constitutes a "disorder" are also reviewed, which serves as a reminder for practicing clinicians that not all depressive symptoms constitute a "disorder." These distinctions and their implications for treatment—watchful waiting versus immediate treatments—are discussed. The book is also a cautionary tale for those conducting depression research, shaping policy, and developing DSM-V. Finally, the discussion about whether intense sadness has any usefulness or should be "medicalized" in efforts to eradicate it from our lives is thought provoking for all readers. Overall, a more thoughtful discussion of this topic between clinicians and with patients may lead to better treatments and outcomes.