A Few Questions For Allan Horwitz
Amid claims that one out of ten Americans suffer from Depression, and that 25% succumb at some point in their lives, Allan V. Horwitz and Jerome C. Wakefield argue in their new book, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder that, while depressive disorder certainly exists, the apparent epidemic in fact reflects the way the psychiatric profession has understood and reclassified normal human sadness as largely an abnormal experience. Allan V. Horwitz, PhD, is a Professor of Sociology and Dean of Social and Behavioral Sciences at Rutgers University and has been kind enough to answer a few questions about his new book for us. Check back later today for an excerpt.
OUP: In your introduction you mention that you work in the sociology of stress. Can you explain what it is and how it led you to work on this particular book with Dr. Wakefield?
Allan Horwitz: The sociology of stress is concerned with the impact of stressful life events – such as marital dissolution, unemployment, receiving a diagnosis of a serious physical illness – and of chronically stressful conditions – such as living in poverty or having continuing abusive social relationships – on mental health. One of its basic assumptions is that the reasons for why people become distressed and unhappy lie in their stressful circumstances, as opposed to their internal personality or biological characteristics.
My work in this area convinced me that many unpleasant emotions and, in particular, sadness stem from normal people’s responses to stressful conditions, not from their having mental disorders. In contrast, it seemed as if the mental health professions did not distinguish normal sadness from psychiatric disorders and counted all conditions that reached a severe enough level as signs of disorder. However, dire social circumstances could produce normal sadness as well as major depressive disorder so there is a fundamental need to separate normal from abnormal emotions.
Oup: Your book talks about the Diagnostic and Statistical Manual of Mental Disorders’s definition of depression. Why has the DSM-III’s definition of depression contributed to the rise in its diagnosis?
Horwitz: Beginning in 1980, the DSM began to use a checklist of symptoms to define depressive disorder. If people had enough symptoms – at least five symptoms that must include either a sad mood or an inability to experience pleasure as well as symptoms such as loss of appetite, sleep difficulties, fatigue and several others. However, with the sole exception of people who develop enough of these symptoms after experiencing bereavement, the diagnosis ignores the context in which such symptoms develop. So, a person who feels sad, loses their appetite, can’t concentrate, etc. for two weeks after experiencing a romantic breakup, the loss of a job, or having a child seriously injured in a car accident is treated as equivalent to someone whose symptoms have no environmental cause or that have persisted for long periods of time. Because the definition encompasses such normal sadness responses, in addition to symptoms that are genuine mental disorders, the apparent rate of depressive disorder has greatly increased in recent decades. In the book we argue that the rising rate of depression is more a result of the changed definition of depression than of the fact that there are actually more people with depressive disorders in recent years.
OUP: How can an individual separate normal anxiety and depression from a disorder that needs to be treated by a doctor?
Horwitz: Normal depression and anxiety has three primary characteristics. First, it develops in close proximity to some stressful occurrence in the environment so that people are responding normally to their immediate circumstances. Second, it is of roughly proportionate seriousness to the severity of the circumstances people find themselves in. Finally, it lasts approximately as long as the stressful circumstances persist or it gradually goes away as people adjust to the loss they have suffered. If symptoms are of unusual severity or persist for a couple of months after a highly stressful event, it is worth seeking help from a physician or mental health professional.
OUP: What does the over-diagnosis of depression say about our society?
Horwitz: What we see as this over-diagnosis stems from several social trends. The pharmaceutical industry has become a very powerful force that not only sells products to treat mental illness but also finances the advocacy efforts of mental health lobbying groups and research about mental health. This industry has an obvious interest in broad definitions of depression and other mental illnesses. Second, beginning in 1997 direct-to-consumer advertising has been allowed, leading to ubiquitous messages that people should seek medical help for common symptoms of sadness, anxiety, fatigue, etc. People themselves are often very willing to want remedies, such as medication, that promise quick and easy relief from their psychic suffering and so are highly receptive to these messages. Moreover, mental health professions can only receive reimbursement for treating people who have specific disorders and so are receptive to definitions that provide broad definitions of these disorders. In addition, researchers like the symptom-based definitions of depression and other mental disorders that the DSM contains, which are much easier to use than definitions that would have to make difficult decisions about whether sad and anxious feelings are an appropriate response to stressful circumstances. Finally, agencies such as the National Institute of Mental Health, which sponsors much research about mental health and illness, finds definitions that call common life problems “diseases” or “illnesses” much more politically palatable than calling them “social problems” that would require changing social circumstances. So, there are many reasons for the over-diagnosis of depression and many groups that benefit from such over-diagnosis. Conversely, there really are no interest groups that promote normality.
OUP: What dangers are there in redefining the definition of depression?
Horwitz: We argue that the current definition of depression is likely to result in many false-positive diagnoses, where normal people who do not in fact have a depressive disorder are diagnosed as being disordered. In contrast, the current definition makes it unlikely that people who are actually disordered will be wrongly seen as well. The danger of using context to distinguish normal sadness from depressive disorder is that some people who are genuinely depressed will be seen as responding normally to their circumstances. So, whenever a definition of a mental disorder, such as depression, is made more stringent, the probability of false positives will go down but the probability of false negatives – calling disordered people “normal” – will go up. The best definition will provide the optimal balance between making these two types of errors.
OUP: What is your favorite book?
Horwitz: I read quite a bit of fiction and my favorite novels, such as Madame Bovary or Anna Karenina, seem to involve central characters whose extreme emotions stem from their social relationships and circumstances. My favorite non-fiction books about psychiatry include Edward Shorter’s From the Mind into the Body, David Healy’s The Anti-Depressant Era, and Elizabeth Lunbeck’s The Psychiatric