By John Cloud
In the 1960s, the pharmaceutical company Sandoz marketed its new tranquilizer Serentil with ads in medical journals suggesting the drug be prescribed to “the newcomer in town who can’t make friends… The woman who can’t get along with her new daughter-in-law. The executive who can’t accept retirement.” But the FDA stopped the ads. Drugs are supposed to treat illness, the agency said, not the vicissitudes of living.
Isn’t that a quaint idea? The FDA was worried back then about an overmedicated society; in 1956, 5% of Americans were on tranquilizers. But today 7% of Americans are on antidepressants (many more have tried them), and ads have touted the drugs for ordinary problems like fatigue, loneliness and sadness. Still, drug companies aren’t the (sole) villain in this story. As Allan Horwitz and Jerome Wakefield point out in their incisive new book The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (Oxford; 287 pages), we now have a “legal drug culture” built around the widely accepted idea that feeling blue is an illness. Horwitz, dean of social and behavioral sciences at Rutgers, and Wakefield and expert on mental-illness diagnosis at New York University, agree that depression can have biological roots. But they persuasively argue that many instances of normal sadness – the kind that descends after you lose a job or get dumped – are now misdiagnosed as depressive disorder. They also point out that the human capacity to feel sad is an evolutionarily selected trait that we might not to want to drug away. They raise a great question: What if sadness is good for you?
We’ve been living in an age of melancholy for at least two decades. Outpatient treatment of depression rose 300% between 1987 and 1997. But while it’s tempting to blame our culture – fear of terrorists, too much caffeine, living by BlackBerry – there’s a more straightforward explanation for the boon in dejection. In 1980, the American Psychiatric Association published a new definition of depression in the Diagnostic and Statistical Manual of Mental Disorders – usually shortened to DSM – the compendium used by mental-health professionals to make diagnoses. The new definition was a radical departure from the old one, which had described “depressive neurosis” as “an excessive of depression due to an internal conflict or to an identifiable event such as the loss of a love object.” The much longer 1980 definition (which is still used, with slight modifications) omitted the requirement that symptoms be “excessive” in proportion to cause. In fact, the revised manual said nothing about causes and listed symptoms instead.
To be diagnosed with major depressive disorder today, you need have only five symptoms for two weeks, which can include such common problems as depressed mood, weight gain, insomnia, fatigue, and indecisiveness. The DSM does make an exception for bereavement: if you recently lost a loved one, such symptoms are not considered disordered. But manual doesn’t make exceptions for other things that make us sad – divorce, financial stress, a life-threatening illness.
Isn’t it safer to have a broad definition so that no truly ill person slips through? Yes and no. Untreated mental illness can be serious, but misdiagnosis can also be harmful: a healthy individual might take unneeded drugs that have side effects, for instance. Also, a psychiatric diagnosis can be used against you in divorce proceeding or disqualify you from, say, a cancer-drug trial.
Still, is there anything wrong with medicating normal sadness if you don’t mind side effects? Horwitz and Wakefield take no position on this. They point out that woman giving birth takes painkillers even though pain is a normal part of the process. But the authors also note that “loss responses are part of our biological heritage.” Nonhuman primates separated from sexual partners or peers have physiological responses that correlate with sadness, including higher levels of certain hormones. Human infants express despair to evoke sympathy from others. These sadness responses suggest sorrow is genetic and that it is useful for attracting social support, protecting us from aggressors and teaching us that whatever prompted the sadness – say, getting fired because you were always late to work – is behavior to be avoided. This is a brutal economic approach to the mind, but it makes sense: we are sometimes meant to suffer emotional pain so that we will make better choices.
We might want to return to a simple definition of mental illness offered by Aristotle: “If fear or sadness lasts for a long time, it is melancholia.” In that case, see a doctor. But if your boyfriend just left you and you can barely get out of bed, don’t assume you’re ill. Your brain is probably doing exactly what it was designed to do.
Ref: TIME, August 27, 2007