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Major Depressive Disorder or Normal Sadness?

Posted Nov 24 2008 2:08pm 3 Comments
An important question in the new issue of Psychiatric Times:
A diagnosis of MDD is warranted, according to DSM, when a patient has at least 5 of 9 specified symptoms for at least 2 weeks, and the 5 symptoms include either depressed mood or an inability to derive pleasure from life. The sole exception is that bereaved patients are not considered to have a disorder if they otherwise meet the criteria, as long as their symptoms are not unusually severe and last no longer than 2 months. The reason for the bereavement exclusion seems obvious: people who respond to the loss of an intimate with intense sadness, sleep and appetite difficulties, a loss of concentration on usual roles, and the like, do not have a mental disorder. Rather, they are responding normally to a situation of intense loss. The distinction between sadness that is a normal result of painful losses and depressive disorder is a fundamental one that has been explicitly recognized throughout the 2500-year history of psychiatric medicine.

Yet, the bereavement exclusion raises the question of whether people with enough symptoms to meet the MDD criteria—after, for example, the unexpected loss of a valued job, the collapse of a marriage, the failure to achieve a highly valued goal, or the diagnosis of a life-threatening illness in oneself or a loved one—are similarly reacting normally to situations of intense loss. For thousands of years, until DSM-III, physicians understood that these kinds of situational contexts were an important consideration in determining whether someone was experiencing normal—although intensely distressing—sadness or a depressive disorder in which something has gone wrong with mood processes and the sadness symptoms are no longer linked to the situation or likely to remit over time. Unlike many other diagnoses in DSM, which contain qualifiers that require symptoms to be “excessive” or “unreasonable,” no such qualifiers exist for MDD. Aside from the bereavement exclusion, the diagnostic criteria do not take into account the context in which symptoms arise.

Ample scientific evidence—ranging from infant and primate studies to cross-cultural studies of emotion—suggests that intense sadness in response to a variety of situations is a normal, biologically designed human response. Recent epidemiological analysis suggests that the consequences of stressors can be either normal or abnormal, similar to those for bereavement.1 In its quest for reliability via symptom-based definitions that minimized concern with the context in which the symptoms appeared, DSM unintentionally abandoned the well-recognized, scientifically supported, indeed commonsensical distinction between normal sadness and depressive disorder.
Along these lines, what about an addict who burns their life to the ground in their addiction? Even the exclusionary criteria are limited to physiological effects of drugs. In many cases, are depressive symptoms in the face of a life ravaged by addiction not a sign of intact reality testing, an indication of some strengths, or, at least, a possible crack in denial? Should depressive symptoms in the face of these difficulties really be treated as mental illness? Isn't it an indication of some mental wellness?

[hat tip: Andrew Sullivan]
Comments (3)
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Hi, Mr. Schwartz--For another view of the "bereavement exclusion" issue, please see the article by Dr. Sidney Zisook and me, posted on the Psychiatric Times website: "DSM5 Criteria Won't Medicalize Grief, if Clinicians Understand Grief."

  And, remember Einstein's definition of "common sense": the prejudices we acquire prior to the age of 18! 


Best regards, Ronald Pies MD

Thanks for the comment and link. Care to expound on your reference to Einstein's definition of "common sense"?

Sure, thanks, Jason...I was discussing "common sense" in the context of the argument put forward by Profs. Jerome Wakefield and Allan Horwitz ("The Loss of Sadness"). They argue (among many other points) that "common sense" tells us that major depressive symptoms following a recent loss are different than a bona fide major depressive disorder.

Einstein's point is that science is not "common sense"--if it were, we would be standing on a flat earth with the sun revolving around us! The best science to date does not support the Wakefield-Horwitz position, in our view (Dr. Zisook and me). For a more detailed analysis of the W-H thesis, please see my piece in Psychiatric Times, "Major Depression After Loss is Major Depression--Until Proved Otherwise."

None of this, of course, implies that medication is necessarily required for folks who meet major depressive episode criteria after a recent loss--it merely means that the presence of a recent loss (bereavement, job loss, etc.) does not "immunize" the person against all the consequences of major depression, nor does it predict clinical course, outcome, response to treatment, etc. 

 Best regards, Ron Pies 

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