Standard criteria for diagnosing depressive disorder does not adequately distinguish intense normal sadness from biologically disordered sadness.
Feeling depressed? You’re not alone. Treatment of depression in outpatient services increased by 300% toward the end of the 20th century. Antidepressant medications have become the largest selling prescription drugs in America. During the 1990s spending increased by 600% exceeding 7 billion dollars annually by the year 2000. Estimates indicate that Major Depression afflicts 10% of Americans.
Depression is real and, as a recent commercial reminds us, it hurts— everyone. Depression must be treated with care and sensitivity. But why has there been such an explosive growth of depression in our culture? Is it possible that our expectation for gregariousness is unrealistic? Have we been led to believe that there is no place for sadness in normal life?
Is it also possible that we are misdiagnosing normal sadness as depressive disorder because we do not understand the differences between them?
In, The Loss of Sadness: How Psychiatry Transformed Normal Sadness Into Depressive Disorder, Alan V. Horwitz and Jerome C. Wakelfield offer careful analysis of what has been called the age of depression. They suggest that standard criteria for diagnosing depressive disorder does not adequately distinguish intense normal sadness from biologically disordered sadness. Their aim is to offer a critique of what they view as the “over-expansive psychiatric definitions of disorder.” They offer extensive insight for distinguishing “sadness due to internal dysfunction” from “sadness that is a biologically designed response to external events.”
Most doctors use the accepted criteria of the Diagnostic and Statistical Manual of Mental Disorders for issuing prescriptions for antidepressants. The Manual requires that five symptoms out of the following nine be present during a two-week period (the five must include either depressed mood or diminished interest or 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
9. recurrent thoughts of death or suicidal ideation or suicide attempt
One of the difficulties in using the criteria is the crossover of symptoms between normal and disordered sadness. Medical doctors (especially family practitioners) often do not have the time to adequately explore the distinction between normal and disordered sadness.
The authors argue that,
“the recent explosion of putative depressive disorder, in fact, does not stem primarily from a real rise in this condition. Instead, it is largely a product of conflating the two conceptually distinct categories of normal sadness and mental disorders. The current ‘epidemic,’ although the result of many social factors, has been made possible by changed psychiatric definition of depressive disorder that allows the classification of sadness as disease, even when it is not.”
The chapters exploring the anatomy of normal sadness and the failure of the social sciences to distinguish this kind of sadness from depressive disorder should be required reading for all medical and psychiatric professionals. Although distinctions between normal and disordered sadness are not always easily discernable, efforts to make them should lead to more holistic care. By holistic, I mean care that respects the multi-dimensional way God made humans.
To avoid misunderstanding, I strongly believe (as do the authors) that many people have been greatly helped with antidepressant medications. I have recommended medicinal aid on many occasions and I respect those who are willing to try this path. When depression becomes a debilitating reality, medicinal aid is the right and necessary way to counter it. But medication alone is not sufficient. We are more than physical beings with neurological needs.
Based on my counseling experience, I believe that sometimes medicinal aid is a temporary need until life-circumstances and personal responses become more healthy through the assistance of godly counsel.
As one more trained in theology than physiology and psychology, I bring an important consideration to the table. I hold the belief that God created humans as multi-dimensional beings. We are physical beings with bodily needs, social beings with community needs and spiritual beings with spiritual needs. Treatment and care that is holistic must look at each dimension in relation to the others.
As sinful beings living in a fallen world, we must expect hardships. Jesus said, “In this world you will have trouble” (John 16:33). He also said, “Each day has enough trouble of its own” (Matthew 6:34).
Expectations for uninterrupted gregariousness ignore this truth and lead to greater struggles with discouragement and despair. Follow the link below for additional guidance from Scripture.
Millersville Bible Church