Do no harm: Depression’s definition leaves much to be desired

by Aiza Khan / Beacon Correspondent • January 28, 2015

Defining depression can be difficult because of how varied the disease is. With high rates of depression diagnosed nationally—it affects one in 10 Americans, according to a report from the Centers for Disease Control—there is a disconnect between the diagnoses of general unhappiness and the prolonged depressive disorders that require medical treatment. Some diagnoses of prolonged depression could really just be a temporary unhappiness. It is essential we start talking about this distinction to improve our understanding of the disorder and its treatments.

Many contemporary conversations about mental health awareness and aid lack one basic fact: Sadness is a common response to certain situations that naturally occur within one’s lifespan. Sadness is “traditionally viewed as humanity’s natural response to deaths of intimates, losses in love, reversals of fortune, and the like,” wrote researchers Allan Horwitz and Jerome Wakefield.

But the 21st century has brought on the medicalization of sadness—the mindset that sadness is an abnormal attitude that requires professional treatment. So-called symptom checklists, popularized and circulated by pharmaceutical companies, have broadened the general understanding of depression so much that patients experiencing any degree of sadness can now self-diagnose and seek treatment for depression.

True depression, on the other hand, is different and requires more serious attention. It’s rooted in—and, importantly, manifests from—entirely different stressors, requiring an entirely different treatment. It’s more than a hashtag you add when tweeting a complaint about a long Starbucks line. Depression causes inhibition and prevents productivity. It causes breakdowns in our basic psychological systems, unlike normal sadness, and stops people from adapting to new circumstances.

The Diagnostic and Statistical Manual of Mental Disorders, or DSM, the industry standard book that offers a common language and a standard criteria for classifying mental disorders, is a major contributor to the medicalization of unhappiness. The fifth and most recent edition of the DSM contains numerous categories of mental illness and even more subcategories. “Depression” is broken down to a number of subtypes, which is then further broken down into symptoms that include those of everyday unhappiness. 

That such an influential publication would blur the boundaries between ordinary sadness and medically-treatable sadness means that even health professionals may start considering them to be the same. Depression is, and should always be, seen as a condition that is serious and sometimes life-threatening. But the DSM’s list of symptoms for depression make it extremely difficult to differentiate normal, temporary unhappiness from the true prolonged mental disorders.

The DSM’s expanded definitions also happen to be well-suited to help the market for psychotropic drugs grow. Though there’s no evidence that pharmaceutical companies are consulted for updates to the DSM, they certainly benefit. There has long been a nationwide shortage of psychiatrists, as the Pittsburgh Post-Gazette reported in March, so pharmaceutical companies created symptom checklists for general physicians and patients to use. For depression, checklists generally include symptoms like feeling low and lack of energy. This allows nonspecialist doctors to diagnose “depression” following the DSM’s determinations, even though they may overlook individual, contextual reasons why that individual may feel a certain way.

In 2012, Pauline W. Chen, a contributor to the New York Times’ Well blog, looked at those checklists and their profitable relationship to marketing. “What makes the checklists so powerful is their ability to influence patient preferences,” Chen wrote. With these depression checklists readily available online, individuals can now “check” themselves for symptoms and seek perhaps unnecessary professional help. What may seem like a way to gain a better understanding of one’s emotional state might actually hurt more people than it helps.

What can make a difference is drawing a clearer distinction between normal sadness and depressive disorders. Talking about this distinction needs to be a bigger part of the national conversation so we can truly improve our understanding of the disorder and its treatments.