Victor Hugo once described melancholy as “the pleasure of being sad”. Few now
have the chance to experience that pleasure.
Sadness, according to a group of influential American psychiatrists, has taken
on a clinical alter ego – depression – and is steadily being medicated into
oblivion. In Britain, 31 million prescriptions for antidepressants were
issued last year, a record high. Our Prozac nation is now also steeped in
Seroxat; we increasingly turn to serotonin boosters to soothe our sorrows.
And yet, as a powerful book points out, sorrow is not a disease but a natural
emotion, as vital to our wellbeing as happiness. The Loss of Sadness: How
Psychiatry Transformed Normal Sorrow into Depressive Disorder argues that
the ability to feel sad has survived hundreds of thousands of years of human
evolution and must be of benefit.
“While depressive disorder certainly exists and can be a devastating condition
warranting medical attention, the apparent epidemic (in depression) reflects
the way the psychiatric profession has understood and reclassified normal
human sadness as largely an abnormal experience,” write Allan Horwitz,
professor of sociology at Rutgers University, and Jerome Wakefield,
professor of social work at New York University.
Their book demonstrates how medicine has lost sight of the context in which
people can become sad; the definition of depression requires only the
appearance of symptoms such as insomnia, change in appetite and fatigue. As
a result, people who are downcast for valid reasons, such as the end of a
relationship or the loss of a job, can be mistakenly deemed depressive.
Despite their natural reaction to a misfortune, they are crowded under the
same diagnostic umbrella as the poor souls who feel sad for no reason; it is
only the latter whose brains are functioning abnormally and require
treatment.
Horwitz and Wakefield are respected academics in the field of mental health;
their book has already prompted widespread soul-searching about how
depression is defined. “[The authors] make a persuasive argument that has
major public health implications,” comments Michael First, professor of
clinical psychiatry at Columbia University Medical Centre and editor of the
Diagnostic and Statistical Manual of Mental Disorders (fourth edition).
The DSM-IV, as this manual is known, is the checklist used by psychiatrists
worldwide to diagnose all the mental disorders recognised by the American
Psychiatric Association. The new edition, DSM-V, is set to be published in
2011; there is a growing call for major depressive disorder (which
encompasses most depressive disorders) to be reframed in the terms that
Horwitz and Wakefield suggest. But perhaps the most surprising string to the
book’s bow is the author of its foreword: Robert Spitzer, professor of
psychiatry at the New York State Psychiatric Institute. Spitzer is described
by The New Yorker as “one of the most influential psychiatrists of the 20th
century”. He was the driving force behind the third edition of the DSM;
before its publication in the late Sixties, it was common for psychiatrists
to differ wildly in their diagnoses of a condition in the same patient.
Spitzer’s work resulted in a reliable, comprehensive dictionary of definitions
that all professionals could use; under his stewardship, the diagnostic
manual became a universal compass helping medics to navigate the complex
territory of mental disease with confidence.
He calls The Loss of Sadness a “brilliant tour de force” and a “water-shed” in
the development of the field. More tellingly, Spitzer admits that “Dr
Wakefield has critiqued my efforts in ways that I have largely become
convinced are valid . . . (the DSM’s) diagnostic criteria specified the
symptoms that must be present to justify a given diagnosis, but ignored any
reference to the context in which they developed. In so doing, they allowed
normal responses to stressors to be characterised as symptoms of disorder.”
The book, Spitzer reveals, “has caused me to rethink my own position . . .” It
is probably the closest you will ever come to hearing a doctor of Spitzer’s
stature admit that he was wrong. The book’s central thesis is that sadness
seems always to have existed. All cultures experience sorrow; human infants
are born with a tearjerking ability to express it. Even the type of grief we
experience at various events is remarkably consistent: those who miss a life
goal, such as a wanted promotion, feel pessimistic and tired, while the
bereaved tend to cry and report physical pain. That chimpanzees, with whom
human beings share a common ancestry, can appear mournful when life turns
against them, indicates that sorrow has long been woven into the emotional
fabric of human evolution.
These facts suggest that virtually everyone has an innate biological capacity
to feel sad; so it is sensible to assume, as the authors do, that a good
evolutionary reason lies behind the preservation of sadness as a
psychological trait.
Dr Dylan Evans, an evolutionary psychologist and author of Emotion: The
Science of Sentiment, says it is clear that the ability to feel sad has been
honed over millions of years. “It must be an innate capacity that has come
to us through evolution, because it is a basic, universal emotion,” he says.
“People don’t have to learn to be sad; blind people who have never seen
faces produce the same facial expressions. Just like other basic emotions,
such as happiness, fear and disgust, sadness has all the hallmarks of an
adaptation.”
Evans accepts, though, that the benefit that sorrow brings is not clear.
“Disgust helps you to avoid rotting food, and fear makes you avoid wild
animals and the dark. The function of sadness is more difficult to work out.
“One possibility is that it makes you stop and reflect on what you’ve done,
and it’s a way of stopping mistakes in the future. The problem with this is
that sad people often don’t think logically or creatively, and don’t learn
from their mistakes. Another theory is that it initiates support from other
people.”
People who cry, for example, are usually quickly surrounded by sympathetic
individuals. Evans elaborates: “Some people have speculated that clinical
depression is an attempt to extort, rather than elicit, support.”
Another theory suggests that sadness helps to protect the hierarchical nature
of human society and thus prevents anarchy: “When you see people higher up
the pecking order you feel sad, and that sadness stops us from making risky
challenges to those higher up.”
Only when intense sadness has no clear cause, or lingers longer than usual,
should it be considered dysfunctional, and be treated medically. The Loss of
Sadness points out that this distinction is not made in the way that major
depressive disorder (MDD) is defined. In particular, it takes no account of
personal circumstances (except for bereavement).
For a diagnosis of MDD in a person, he or she should have displayed at least
five of the following nine symptoms over a two-week period (the five must
include at least one of the first two symptoms): depressed mood; a lack of
interest in activities; change in appetite or weight; insomnia; or
hypersomnia (excessive sleep); a physical slowdown; loss of energy; feelings
of worthlessness or guilt; inability to concentrate and make decisions;
recurrent thoughts of death or suicide. In the case of bereavement, the
symptoms must endure for at least two months.
A similar range of symptoms can happen naturally to a healthy person after a
stressful event, such as an adulterous betrayal, failing a college test,
learning that a child has cancer, or a public dressing-down. And without
that context being specified, the authors write: “Contemporary psychiatry has
inadvertently characterised intense normal suffering as disease”. In most
cases of normal sadness, the suffering gradually subsides. But by then it is
often too late – he or she is already wielding a prescription for Paxil or
Prozac.
Evans agrees with the idea that normal sadness is overmedicalised; he sees
this as a chance to discover the true function of sadness. “By giving Prozac
out on a massive scale, we are, in effect, creating a huge social experiment
in which sadness disappears.” Knowing what happens in its absence should
give us a clue as to why we are born to feel sad.
Randall Nesse, a psychiatrist at the University of Michigan, once speculated
that economic booms and busts were becoming more extreme because so many
stressed-out investors and traders were on Prozac, which blunted their sense
of caution. When the gambling is heavier, Nesse argued, the bubbles are more
voluminous and the busts more spectacular.
“Anecdotally, people on antidepressants say that they feel untouchable,” Evans
says. “They don’t seem to have that emotional immediacy that most of us
have.” For severe depression, that is a good thing but in healthy
individuals the antidepressants may be desensitising people to vital
emotional cues from others. The idea that depression is often an unjustified
medicalisation of a normal human emotion is gaining currency in this
country, too. Earlier this month, Mark Rapley, professor of clinical
psychology at the University of East London, organised a conference entitled
“Demedicalising Misery”, featuring speakers who believe that much normal
behaviour is wrongly classified as disease, and/or the benefits of
antidepressants are oversold. The conference was a sell-out.
Rapley regards the current epidemic in depression as a social and cultural
one, not a bona fide clinical one. “How is it that we have become so
bamboozled that we fail to recognise certain human experiences, such as
grief or sadness, for what they are?” Rapley asks.
And if depression is just normal sorrow, he rails, it’s reasonable that
antidepressants are not correcting some fundamental, underlying brain
deficiency: “If I have a severe headache and take aspirin to make me feel
better, I don’t think of myself as having an aspirin deficiency. If I drink
a couple of glasses of wine before I go to a party and then become the life
and soul, I don’t regard myself as having an alcohol deficiency. If we don’t
believe it for aspirin and Shiraz, why do we accept it for SSRIs (selective
serotonin reuptake inhibitors, such as Prozac)?”
Rapley does not use the word “depression”; he says that he believes in being
“unbearably sad, so sad that you can’t leave the house and you don’t think
life is worth living. I call that what it is: unbearable sadness. I see
nothing wrong with using substances to make yourself feel better. What I
object to is the intellectual trickery, and how the drugs industry has made
us believe that when we feel sad we have something fundamentally wrong with
us that needs correcting.”
The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into
Depressive Disorder, by Allan V. Horwitz and Jerome C. Wakefield, Oxford
University Press, £17.99
I am happy to see a community of souls who are familiar with the truth and necessity of this part of life.
Sadness, I feel, is about partial loss of self or the idea of self. We need to traverse this emotional terrain to discover how life must change. It's beautiful, but not to over-dwell in.
Sally, Illinois, USA
Depression is like a prison sentence, being put inside for something you have not done, and not caused by anything you did. People tell you to take pills, talk and things will get better. Pills do not help they just hide the reason/s for the depression. I have suffered depression for many years since the age of 13. In the past my depression has caused me to behave and do things that i did not believe i was capable of doing. Problem being the ones hurt by those actions are now ready to try and make me take responsibility. They do not understand bless, however this lowness goes for quite a while, and then returns when stress and difficult situations arise. Such as not being able to fix the things that I broke - unintentionally. Life is a learning lesson, - I pray there will be some understanding, clarity and future hope for those sufferers of depression - how can you understand what you cannot see? Like our belief in God we know he exists - yet cannot touch, see, or hear,but he is real.
K.C., London, England
Perhaps depressed people see life too clearly. They see through all the phoniness and platitudes like many of the usual ones repeated here. They've reached a state of enlightenment if you like, and see life for what it is, one which the rest of us losers are too witless to envision. It's true that our society doesn't like unhappy people, although I'm sure Big Pharma likes them. They're expensive to maintain and get in the way of production. They send us a message that we are too weak to bear. Life sucks, always has, always will and that message makes us feel helpless especially since we're inacapable of reaching into another human being to make their pain more bearable. Usually, we react with fear or anger. I'm having fun with my career/date/kids/hobby etc., why aren't you? Why can't you just get on with your life? We don't get it, do we?
Don't get me wrong, I only offer an alternative perspective. I have no answers.
Dave, London, UK
My experience working in a hospital is that psychiatrists are only interested in diagnosing people putting them in a pidgeon hole and prescribing medications.
I would be very careful before going to a doctor and sobbing my heart out to them. Unfortunately by no means every professional has common sense compassion or wisdom and many will just want to tick their boxes and put you on a pill.
Depression/sadness is a natural reaction to loss. To mistakes made. To damage done.
It is a crucial important part of being human. It stops us in our tracks and urges us to reflect on what has happend. It is telling you that for whatever reason you as an organism are failing to thrive one way or other. It is something to heed.
posey, london, UK
In the past four years five of my close friends faced the end of a long term relationship that they had assumed would last forever. All five were obviously in some natural state of grief and went to the doctor to look for a way out of their sadness. Voila Prozac. Now maybe it is because I am a competitive sort, or maybe I was just brought up with a no nonsense attitude, either way I really felt like these girls had been denied the chance of proving to themsleves that they could succeed in navigating the unpleasant path of sadness to emerge remarkably unscathed back on the brighter side of life. Contrastingly another friend of mine was very suddenly, sharply and inexplicably plunged into a deep dark hole of panic and depression. In this case, appropriate medication has helped him heave himself back to a state of normality. I myself suffer depression too, but (perhaps with my sporting background) have come to see it as a gruelling challenge, a chance to do battle, and be victor.
Tina, East Dulwich, London
In some societies (e.g. both pre- and post- revolution Russia), sadness, or melancholy, was a vital part of being an intellectual. If you were happy, you were a fool. Melancholy is absolutely key to classical Russian literature.
Anna, Zurich, Switzerland
Hang on a minute..."If you don't want to be labelled mentally ill and medicated accordingly don't present yourself for diagnosis." What a concerning comment! I hope Carol isn't a GP. I think that this article addresses an incredibly important point. Sadness and depression are very different, yet at their onset can feel identical. Your doctor should encourage you to take steps to identify which you are experiencing. It should not be a foregone conclusion that you be diagnosed as suffering from depression simply because you visit. Whereas normal sadness can act as a springboard to a happier long-term life through recognising your needs and sensitivities, depression can be a debilitating disease that desroys relationships & careers. It does no good to the depressed, or the sad, for the two to be treated as one by lazy practitioners.
L, London,
Sad isn't fashionable.
Society doesn't like sad people around them because it interferes with their [society's] conscience, and they'd then have to think about it. And then society would not be able to have a good time. So it makes out that sad people are undesirable, so should then 'go and get help' , ei, go away somewhere else that's not around us. So we don't have to think.
Catherine Barber, Hungerford, UK
sadness is caused by not having reasons to be happy
when you are depressed you could win the lottery and still turn over and cover your head with a pillow!
A lot of people say they are depressed when life is just not going as they wish....
yvonne R, Cambs, UK
This lunar beauty
Has no history
Is complete and early
If beauty later
Bear any feature
It had a lover
And is another
This like a dream
Keeps other time
And daytime is
The loss of this
For time is inches
And the hearts changes
Where ghost has haunted
Lost and wanted
But this was never
A ghost's endeavour
Nor finished this
Was ghost at ease
And 'till it pass
Love shall not near
The sweetness here
Nor sorrow take
His endless look.
Put that in your pipe on a rainy day and smoke it! Only insane people trust psychiatrists. The rest of us nutters find a shrink who has fallen into sanity but decided to return to the madhouse to tell his tale for the greater good. You can't have joy without sorrow, any more than you can have a kiss without a squeeze, or apple pie without cheese. Someone needs to get their head out of their pumpkin!
Bill Auden, Istanbul, Turkey
If you suffer from depression there is nothing wrong in taking medication - if you had cancer or diabetes it wouldn't be looked down on but depression's an invisible disease. A lot of people don't understand depression as everyone gets down at times and the majority opinion does seem to be 'snap out of it'. It is the one mental illness that people seem to see like that, unlike schizophrenia or autism. Those not suffering from it often tell you being happy is a choice - as if you'e stupid. I've suffered from depression and been on anti depressants for over 6 years, they don't make me feel invinceable, just take the edge off the pain and stop you feeling so suicidal. I've tried many therapies to try and help myself, with acupuncture, meditation, CBT, counselling and nutritional supplements etc. The supplements have been the most helpful and make me feel normal but anti depressants are given as a quick fix and because they make people money due to patents whereas supplements etc don't.
Claire, Cardiff, Cardiff
Clinical depression should be seen as a physical illness not a mental one. When the brain's limbic system 'blows a fuse' - usually due to overwhelming circumstances - depression is the result. Like any other part of the body that isn't working, the limbic system has to be fixed.
Antibiotics cure an infection, antidepressants get the limbic system working properly again. It is not the terrible life events in themselves that cause depression, it is the individual's reaction to them which is key.
The real tragedy in the UK is not overprescription of antidepressants but the lack of support and therapy available to those suffering from depression, and scandalously the lack of funding for treating children.
Jane, Surrey
Jane Hibberd, Weybridge,
Doctors just use antidepressants to get rid of you when you've got something they don't want to treat because it'll cost too much or be too complicated.
They'll palm you off with very damaging tricyclics for everything from severe toothaches caused by infections and bad dentistry to Hypothyroidism which is very debilitating and causes heart disease and obesity but it mostly affects women (and they don't matter) and though it is far cheaper to treat than all the other health problems you get from not treating it, once you are diagnosed Hypothyroid you get free prescriptions for the rest of your life which the `GP's don''t want on their budgets. Instead of changing the rules so thyroid patients have to pay, they tell you you are "normal" no matter how ill you get, and give you antidepressents while you loose your job and your life and end up in the gutter.
Great stuff.
Thalia, London,
Actually being sad from time to time makes you happy! For instance, listening to beautiful music or watching what a movie referred to as a "weepie" - do people on Prozac need any kleenex for that - are valid parts of life. I am one of the happiest people around but love reading very sad poetry and getting sniffly. If you can't feel sad, you can't feel its complement, happiness so all these drugs deadening intense emotion are threats to your humaneness.
Bronwen, san antonio, usa
There are a lot of people out there who belittle depression as an illness. I can guarantee that all of those people have never suffered from it.. Funny isn't it, as with most things in life, you'll only understand it if you've walked a few miles in a depressive's shoes.
Steve Price, Llanelli,
You have to experience sadness to appreciate joy and happiness.
That is what going with the flow is all about.
The deepest darkest moments bring the most enlightenment, but the elite do not want that- do they.??
Medication is the pharmaccy's way of making money out of your misery.
Lilith Barrett, London., UK
I do think that antidepressents are being over- perscribed, but that there definitely is a time and place for them, as well.
After a horrendous childhood and adolesense, I suffered from a pitts of hell like state for most of my early twenties that despite trying everything, and I mean everything, I was unable to reverse. I remember Prozac being like a miracle for me. Within a short period of time I was lifted out of what can only be described as a living hell and was able to begin the long process of sorting out.
That was years ago and I no longer take medications, I am, relatively speaking, "normal" now. I do get sad now, and sometimes depressed for a few days, about "normal" things as far as I can tell and I know that medications would just be overkill. Believe me, the depressions that I have now (rarely) are nothing at all like the state of continual torturous hell that I could not escape from earlier in my life (I assume that was "clinical depression.")
Candis , Baltimore, USA
I look forward to tomorrows story on "Doctors missing diagnosis of depression"
That wheel keeps on turning....
John Powell, Sheffield, UK
Thank God someone people will listen to has finally said this.
Caroline Devitt, Zaragoza, Spain
This is, sadly, about popular culture taking over from the medical profession. People who feel sad are no longer allowed to go through the normal processes of grief and loss, they have to be given a diagnosis. Believe me, I have been sad and I have been depressed: I know the difference. Sadly, the people around me who could have helped me work through it did not.
There is also a tendency to diagnose completely normal post-traumatic reactions as "depression". One friend nearly lost her life and that of her baby to pre-eclampsia in a dreadful hospital. She was completely traumatised, but was told she was suffering from post-natal depression. Why? Because you can throw antidepressants at depression, but PTSD needs a talking therapy.
Perhaps if people did not lead such busy lives and did not feel the need to trample people going through a hard time into the ground to make themselves feel better, people could work through life without medication.
MS, London,
There's a hell of a lot of Malingerers out there that are getting incapacity benefit because of intangible depression. I remember watching Wife Swap a few years ago and there was a beer swilling scouser who was apparently unable to work because of the depression caused by the death of his mum but she had died seven years ago!!
There was nothing wrong with his right arm though as he swigged away at his lagers.
I think he had seven kids, there's nothing wrong with that in itself but he obviously felt that it wasn't worth him getting out of bed in the morning to go and do a job because he could get just as much, if not more in benefits.
The logic of these people doesn't include a sense of pride, just use and abuse, what's in it for me?
Graham, St Albans, uk
Whilst I welcome the differentiation between grief and depression, sadness or 'grief' (whether it be for a person, a relationship, a job...) is entirely different from depression, and the symptoms differ wildly. This book sets the study of depression back 100 years and is based on speculation and sweeping generalisations rather than actual scientific evidence. As yet, no psychiatrist has been able to enlighten the public on the two most profound statements in here: a sense of worthlessness and the suicidal ideation that accompany it.
This book makes light of the fantastic work that has been achieved by both chemical and behavioural treatment, and how for some people, they literally could not live without these advances. For every mis-diagnosis, there are thousands of successful treatments; for every person who comes forward, another three don't. Until stigma is removed from depression, suicide rates will remain inevitably high.
Emma Lee, Bolton, Lancs
Finally some sense!
It is not always the "depressed" person who seeks help, of their own volition, but pressure from employers and family which forces them to do so.
The choice: be "normal" or be sick!
We are no longer tolerant of the process of grief let alone natural sadness of life. Sometimes all that is needed is time out but this is seen as unacceptable weakness. So we medicalise the problem to get time out. This can devastate families and wreck professional lives as people are labelled as "nutters" and consigned to the scrap heap.
My family have suffered from the over diagnosis of depression and further mental illnesses.Medicated, the person involved was unable to function. Things are returning to normal but the effects will never be undone.
Society is very presurised. Sometimes people just need a break, but if they do need pills this does not render them unemployable or stupid.
By definition human beings are sentient not automatons: let's remember and celebrate that!
family member, Harpenden,
It is an unfortunate reality that for ailments that are not really obvious, the chance of getting appropriate treatment in the US is about 50/50. The media and pharmRx companies desire to convince us that we need to live in a state of bouncy joy with no lines on our faces. Most MDs just try and treat the symptoms and as the pharmRx companies have websites that list the S+S of the dysfunction, he gives the patient what they came there for... You cannot medicate severe grief, it will come out later in a worse way if you do. I admit that severe depression needs to be treated in some way. In England where my cousin is a Social Worker, they rarely give drugs, they do cognitive and behavioral therapy. Not that it works all the time either. If you have a sore spot on your foot, you look to see what causes it. If you have a sore spot in your soul, you need to discover the cause.
Kim Ellen Campbell RN MS, Whiteriver, Arizona
Lewis Wolpert put it cleary, depression is 'malignant sadness'; he was able to clearly distinguish between his own dreadful clinical depression and the sorrow he experienced after the death of his wife. Carole it's not so 'simple' really. Try reading Wolpert's book which will give you some insight inotothe vast gulf between ordinary sadness and clinical depression.
Dectora, London, UK
This article will do nothing toward the acceptance of Major Depressive Disorder as an actual illness. I suffer from depression and this affects me far beyond just "feeling sad". I self harm and have attempted suicide, despite treatment. Already I have to deal with the attitude that I should just "snap out of it". I'm sorry to think that some people are being treated who don't need to be, but maybe an article should be written on why science still doesn't understand what depression is, and how to best prevent it. And why we live in a culture that is so unaccepting of such an illness.
K.A., London, UK
When will we understand that psychiatry and science can't explain everything? Love, grief, sadness - these things are part of our spiritual selves and that is outside of the field of science. However I do think serious depression still needs treating.
lottie, christchurch, new zealand
This not only makes clinical sense, it makes common sense.
In 1995, I endured two traumatic deaths in the family--my father and daughter died only days apart. My grief was severe, indescribable and prolonged. I "got over it" in the sense that eventually I resumed a pretty normal life. I had tremendous support from medical professionals OUTSIDE psychiatry (another story), and from one counselor who really understood the dreadful terrain of grief. In the years since, I have talked many times to people new to severe grief. As soon as I "normalize" the experience of prolonged sadness, their gratitude is impossible to describe.
Meds are a tool in the kit, no more, no less. "What I object to is the intellectual trickery, and how the drugs industry has made us believe that when we feel sad we have something fundamentally wrong with us that needs correcting.†Right on! Not just trickery, but cruelty. What happened to "do no harm"? This book is essential. Thanks!
Anne Armitage, Beverly, MA USA
The reality is this - A doctor can only diagnose anything and
that includes depression if the patient pays him a visit and
describes various symptoms upon which the Dr. will make
a diagnosis which could and often is incorrect.
If you don't want to be labelled mentally ill and medicated
accordingly don't present yourself for diagnosis.
I you can't cope and have no way of doing anything about it that is a different matter.
Being sad or unhappy or dissatisfied with ones life is not
mental illness it is normal.
Simple really.
Carol, Perth, Australia
The reason for saddness? because you can have gladness without it.
it guides us to do what is most self-furfilling.
John, Glasgow, UK