by Allan V. Horwitz and Jerome C. Wakefield. New York, Oxford University Press, 2007, 312 pp., $29.95.
The foreword of this book is written by Robert Spitzer, M.D., Professor of Psychiatry at the New York State Psychiatric Institute and the main architect behind the APA task force that created DSM-III in 1980. The central thesis of this book is a persuasive argument that contemporary psychiatry confuses normal sadness with depressive mental disorder because it ignores the relationship between symptoms and the context from which they emerge. Although he remains cautious about the possibility of incorporating situational context into diagnostic criteria, Dr. Spitzer encourages psychiatrists to place this issue on the agenda for the upcoming formulation of DSM-V.
The book’s title is a reminder of the central role of loss as a potentially severe life stressor leading to depression, as well as of how modern psychiatry is being blindsided into extrapolating most states of sadness into depression. In the first chapter, “The Concept of Depression,” Drs. Horwitz and Wakefield address the move toward using descriptive criteria in diagnosing mental illness. In response to criticisms during the 1960s and 1970s about the lack of reliability of psychiatric diagnoses, DSM-III started using lists of symptoms to establish clear definitions for each disorder. The authors argue that this approach, while greatly increasing diagnostic reliability, has created new validity problems (p. 8). In the definition of major depressive disorder, DSM-III “fails to take into account the context of the symptoms and thus fails to exclude from the disorder category intense sadness, other than in reaction to death of a loved one, that arises from the way human beings naturally respond to major losses” (p. 14).
Chapter 2, “The Anatomy of Normal Sadness,” discusses biologically based nonverbal expressions of grief, with emphasis on their universality across cultures and their presence in nonhuman primates and human infants prior to socialization into cultural emotional scripts (p. 39). Besides grief at the loss of a loved one, loss of meaningful relationships, loss of job or status, chronic stress, and disasters are listed as additional factors to be taken into account.
Chapters 3 and 4, “Sadness With and Without Cause” and “Depression in the Twentieth Century,” are a historical review of descriptions of depressive states from ancient times to the present. Disordered sadness is considered “without cause” (or “endogenous” in later terminology), as opposed to sadness “with cause” (or “reactive” sadness), which arises in people who suffer losses. Robert Burton’s classic work The Anatomy of Melancholy, published in 1621, was the first to describe the three major components of depression—mood, cognition, and physical symptoms—that are still viewed as its distinguishing features. In his seminal paper Mourning and Melancholia (1917), Freud made the same distinction between mourning due to conscious losses and melancholia due to the experience of unconscious losses. DSM-III eliminated psychodynamic etiologies, instead focusing on symptoms. In large epidemiological studies, such as the Epidemiologic Catchment Area study in the early 1980s, diagnosis was based on structured tools administered by trained nonpsychiatric interviewers. The authors argue that prevalence data was skewed and advocate for a more specific screening process, as well as careful use of subthreshold diagnoses, such as minor depression.
Thoroughly documented, the first chapters caution readers about the limitations of psychiatric diagnosis. However, momentum is lost in the second half of the book. Chapter 7, “The Surveillance of Sadness,” makes assumptions about psychiatric treatment that are not supported by the literature. For example, it is suggested that in primary care, “diagnosis of a depressive disorder tends to quickly foreclose…discussions in the direction of medication” (p. 156). The recent avalanche of data from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study suggests not only that depressed primary care patients prefer psychotherapy to medication when offered (1) but that therapy is successfully delivered in this setting, along with pharmacologic management (2). In Chapter 8, “The DSM and Biological Research About Depression,” the authors again overreach, selectively analyzing individual cardinal papers and doubting their “range of applicability” without turning to the multiple evidence-based studies available in the literature (p. 176).
Although a poignant reflection on how the misapplication of psychiatric knowledge can decontextualize the lives of its patients, this book seems to miss the point that psychiatric care is a great deal more than diagnostic labeling. In practice, mental health professionals who do not rely exclusively on DSM-IV-TR use biopsychosocial formulations, viewing the individual in his or her context. Thus for many psychiatrists, treatment planning is informed by this comprehensive understanding of the person, and not solely by the description and duration of their symptoms.
1.Gum AM, Areán PA, Hunkeler E, Tang L, Katon W, Hitchcock P, Steffens DC, Dickens J, Unützer J: Depression treatment preferences in older primary care patients. Gerontologist 2006; 46:14–22
2.Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noël PH, Lin EH, Areán PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C; IMPACT Investigators: Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836–2845
Book review accepted for publication August 2007 (doi: 10.1176/appi.ajp.2007.07081263).