In this book Horwitz and Wakefield have brought to light a central problem with the way that American psychiatrists think about depression. The problem, the authors claim, is that psychiatry, and the social sciences which apply psychiatry to non-medical populations, has lost sight of the fact that sadness can be a normal response to adverse situations. Certain events--the break-up of marriage, a failed career, the death of a loved one--often result in a condition that is very similar to that caused by a mental disorder (in this case, depression). However, such responses can be perfectly normal and there is a case to be made that instances of what Freud called 'ordinary human misery' should not be confused with real mental disorder. It is this line of argument which Horwitz and Wakefield seek to elucidate.
The authors start the book by setting out a distinction between 'normal sadness' and 'genuine depressive disorder', arguing that the latter must be separated from the former in order to allow the development of psychiatry as a scientific enterprise. This distinction is brought to light by an examination of sadness in other cultures and times. Whether it be in our own (that is Western) culture a few decades ago, or the Ancient Greek civilization, we can see that sadness has traditionally been viewed as falling into two categories: the appropriate and the diseased. The next stage in their argument is to see how the former has dissolved into the latter in contemporary American psychiatry. To do this the authors chart the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a book often referred to as the "psychiatric Bible".
The DSM lists all the mental disorders that are currently recognized by American psychiatry. Each category--depression, schizophrenia, anorexia nervosa et al.--comes with a "Chinese menu" style symptom list that the psychiatrist can use to check off the patient's problems: 'depressed mood', 'change in appetite', 'loss of pleasure', etc. Horwitz and Wakefield argue it is this very system, which is entirely focused on symptoms and not causes, that is responsible for the loss of sadness. They also note the irony that this same system was introduce into the DSM in order to save psychiatry from the anti-psychiatry movement of the 1960s that, in part, lambasted psychiatry for not making consistent diagnostic decisions (i.e. failing to always diagnose depression given the same set of symptoms). The problem now is not whether psychiatrists can call a set of symptoms 'depression' but whether what they call depression is really a mental disorder.
The problems Horwitz and Wakefield detect in psychiatry are not restricted to the inpatient psychiatric hospital wards. Indeed, the second part of the book shows, in depth, the movement of psychiatry out of the clinic and into the community. It is the increasing use of 'screening programs' based on the DSM criteria, which are designed to spot potential cases of mental disorder as well as untreated cases, in our schools and other 'nonclinical' settings that make the issues Horwitz and Wakefield raise pertinent to one-and-all. Perhaps this is the more important part of The Loss of Sadness. The irony is that the great project to renew and revive the DSM in 1980, which the authors do discuss, was aimed to undo the wrongs of post-war psychiatry that maintained the large majority of people suffered from mental illness. The problem with this claim was that it fuelled the anti-psychiatry movement's fire; people rebelled against the charge they were ill, no matter what the psychiatrist thought. The DSM tackled this fear of 'over-medicalization' by narrowing the remit of psychiatry to only those presenting themselves as in need of treatment. But through lower threshold for symptom detection in the new screening program, we are risking repeating this past mistake.
To solve this problem, Horwitz and Wakefield argue that there should be a refocus on the distinction between 'normal sadness' and 'genuine depressive disorder' via two amendments of the DSM. Firstly, when sadness is in response to an event and is seen as an appropriate response, diagnosis should be withheld (this is already the case with bereavement). Secondly, diagnosis should only be applied in cases where there is an 'evolutionary dysfunction'. Unfortunately, one weakness of The Loss of Sadness is that it fails to make a cogent argument for the second of these amendments. Indeed, one will have to go and look at Wakefield's other work to fully understand the reasoning behind the move from a clinician's diagnosis to the dysfunction of an evolutionary mechanism.
Part of the reason for the appearance of this book is surely that the DSM is currently going through a process that will lead to the production of its fifth edition, and the American Psychiatric Association has said that it is looking at how the definition of mental disorder could, or should, be changed. And that is of course exactly what The Loss of Sadness is about: how should we define depression qua mental disorder. Like Horwitz and Wakefield, the APA are also concerned something isn't right with the DSM, and in particular they note that the rise of screening programs is leading to a growing concern in the general population that 'normal' experience is being medicalized. This is such an obvious case of the past repeating itself that more attention could have been paid to it in Horwitz and Wakefield's analysis to make the link clearer.
Overall this book is written in an accessible style and works as a powerful critique of modern American psychiatry (and since much of the world follows the APA's lead its importance is even more encompassing). The arguments found in The Loss of Sadness will make anyone who listens think about how psychiatry, as well as society at large, is dealing with the phenomenon of sadness.
© 2007 Ian Jakobi
Ian Jakobi ([email protected]) after undergraduate studies in psychology has recently completed a postgraduate course in the philosophy of mental disorder at King's College London and is seeking to extend his studies in the philosophy and history of psychiatry.