Abstract
The title of this book suggests that this is another anti-psychiatry polemic and therefore easily dismissed. Neither author is a psychiatrist: Allan V. Horwitz is a professor of sociology while Jerome C. Wakefield is a professor of social work. It seems a little odd therefore that the foreword is by Robert Spitzer, who was the head of the American Psychiatric Association's taskforce that in 1980 created the DSM-III. It seems even odder that he calls the book ‘the most cogent and compelling ‘inside’ challenge to date to the diagnostic revolution that began almost 30 years ago in the field of psychiatry’ (Foreword vii).
It is this hyperbole? Well, yes and no. Challenges to our current conceptualization of major depression have been increasing for at least the past decade but none has been as detailed and, well, cogent as this book. The ‘inside challenge’ comment is interesting. Both Horwitz and Wakefield believe depression is a medical disorder. Wakefield in particular has published widely on conceptualizing psychiatric disorder as harmful dysfunction based on evolutionary principles; an idea that has received considerable support from the psychiatric community. The authors’ major theme is that both those who believe that depression is the disorder expressed in DSM and those who deny that depression is a medical disorder are wrong. Instead of trying to decide between these rival views, they argue that psychiatry should be drawing a distinction between the genuinely disordered and those with a normal response to sadness whom the DSM has misclassified.
Horwitz and Wakefield review the history of sadness and depression arguing that DSM-III's largely decontextualized, symptom-based criteria stem mainly from efforts to enhance reliability to bolster the scientific credentials for psychiatry. The urgent need for reliability resulted in the rejection of the clinical tradition that explained the context and meaning of symptoms when deciding whether someone is suffering from intense normal sadness or a depressive disorder. The result is a massive pathologization of normal sadness that ironically can be argued to have made depressive disorder less, rather than more scientifically valid.
They argue for context to be reintroduced into sadness, or ‘with cause’ versus ‘without cause’ as Kraepelin conceptualized classification. The problem with decontextualization is particularly troublesome in community studies. Here the unproven idea that symptom checklists could be used by non-clinicians to obtain psychiatric diagnoses comparable to those that psychiatrists would obtain was introduced by researchers. This leads to what Horwitz and Wakefield term the myth of equivalence of community and clinical diagnoses.
Those who seek help from clinicians are by definition self-selected and use contextual information to decide for themselves whether their symptoms exceed ordinary and temporary responses to stressors. Clinicians then hopefully use their commonsense judgement when applying diagnostic criteria. In contrast, symptom-based diagnoses in community studies consider all persons who report enough symptoms as having the mental disorder ‘depression’. The inflexibility of symptom ascertainment and lack of judgement result in large numbers of false-positive diagnoses. Rather than community surveys uncovering high rates of depressive disorder the authors argue that these surveys plausibly demonstrate that the natural results of stressful social experiences (which are common) could be distressing enough to meet symptom criteria for a disorder.
The resulting high rates are used to argue that depression is a public health problem of epidemic proportion, that untreated depression creates vast economic costs and that mental health services are inadequate. And the problem is? You might ask. Surely such an approach reduces stigma for our patients and increases funding for mental health services and research, benefiting patients, doctors, researchers and advocates as well as anyone involved in selling cures for depression.
Horwitz and Wakefield argue that in the long run we cannot claim to base our practice on scientific principles and not question the validity of the DSM concept of major depression. Mixing together normal and disordered individuals in research samples hinders progress in understanding aetiology or improving treatment. Medicalizing distress may potentially label the disadvantaged as mentally ill, replacing appropriate social policies with unwarranted medical treatments. Treating normally sad people as having depression may reduce their sense of personal responsibility, with individuals seeing themselves as passive sufferers of a biochemical deficiency. The magnitude of the figures on depression may paralyse the will to respond; already critics argue for excluding depression on some health insurance schemes. Finally, if all depressive symptoms are a sign of illness what is left of normal sadness? Are we shrinking the range of normal emotions?
These are important questions and this is an important book. There are caveats; at times the book is repetitive; there is little clinical insight, for example there is little discussion of the qualitative differences in depressive symptoms versus sadness. Such things as whether the individual's low mood is comprehensible to them or not, whether they suffer from beliefs that are not yet delusional but outside the patient's normal experience (what German psychiatry called wahnstimmung), the phenomena of psychomotor changes and so on. But it could be reasonably argued that psychiatry itself has largely forgotten the importance of these qualitative differences since the advent of DSM-III.
I strongly recommend this book to all workers in the mental health field. While everyone may disagree with parts of it, it is thought provoking and attempts to be balanced. It is also clearly written without the sociological jargon that obscures many general books written about mental illness. Hopefully it will contribute to getting psychiatry to start thinking again.