Where do we draw the line between sadness and depression?

Imagine you lost someone really close to you. In the next few weeks, feelings of sadness and emptiness dominate your emotional life. Tears run down your face often, without any obvious trigger. During the day, it’s difficult for you to concentrate on your work, and things you usually enjoyed before now have much less meaning to you. In the evenings, you need more time than usual to fall asleep. During the night you wake up more often than before. Something’s happened to your appetite, too. You eat much less or (more often) much more than before.

The previous paragraph can be described in two words: clinical depression. However, DSM-IV (The Diagnostic and Statistical Manual of Mental Disorders) has rules that prevent the diagnosis of clinical depression in case the symptoms have appeared after a loss of a loved one. The grief after a loss of a loved one can be treated as a mental disorder in two cases:

  1. If the depressive symptoms last longer than two months with non-changing intensity, and the sufferer feels that they prevent them from functioning properly
  2. If, besides the standard, the person shows a set of cognitive symptoms: feeling guilty for someone’s death, feeling worthless, contemplating suicide, hallucinations connected with the deceased person

This is called the the “exception of bereavement”.                              

But why has a distinction been made only in case of a loss of a loved one? In other words, why doesn’t the same thing apply in case of a divorce, loss of job, or being diagnosed with a terminal illness?

American Psychiatrists Association, the publisher of DSM, has been struggling with this question for a few decades. The way it choose to respond – with a revision of the Manual – shocked a big part of the psychiatric community. When the DSM-IV ceased to be current, and the DSM-V replaced it, so did the exception of bereavement.

Work on the new version of the manual has been criticized for 4 years now. The removal of the requirement of exception of bereavement – in case of depression – has been considered a part of a bigger plan – plan to manufacture disorders and patients, with the “support” from the pharmaceutical industry.

Manufacturing depression

Taking into account the current prevalence of depression in the developed world, it might seem unusual, but depression was first defined as a mental disorder only recently, in 1980. DSM-III, then the current version of the Manual, as well as the International Classification of Diseases (ICD), published at the same time by the World Health Organization, were the first to outline guidelines for diagnosing psychiatric illnesses like depression.

The list of symptoms of depression remained almost the same, however, what changed were the diagnostic criteria, and the direction of change is consistent with the plan to pathologize and medicalize every condition that deviates from the norm. With time, the criteria for diagnosis have become more and more broad, and currently around 30% of all people in the industrialized world can be diagnosed with depression.

As per DSM-III guidelines, published in 1980, a person which develops symptoms of depression as a result of a loss of a loved one, can be diagnosed with depression only if the symptoms remain unchanged for 12 months. The next version, DSM-IV, published 10 years later, the period has been lowered to 2 months, and in the current version, the DSM-V, the period has been removed completely.

Using data from the National Comorbidity Survey, which uses a representative sample of the U.S. population, Jerome Wakefield, professor of social work at the University of New York, tried to measure the effect of lowering diagnostic criteria for depression, which happened after the switch to DSM-IV.

From the sample of around 10 000 Americans, Wakefield and his associates have isolated around 156 cases of depression caused by a loss of a loved one. Then they applied the diagnostic criteria for depression from DSM-III and DSM-IV. According to the first manual, around 45% of the sample could be diagnosed with clinical depression. According to DSM-IV, the percentage was almost doubled, to 80%.  

This difference in percentages isn’t unusual. This is just a statistical result of more inclusive criteria. But that doesn’t mean that the more inclusive criteria are inherently bad. So, which of the two diagnostic manuals is better, more correct? Here is how Wakefield tried to solve this question.  

He split the source sample into two subsamples:

  1. Cases which display complicated grief and match the criteria for diagnosis of clinical depression
  2. Cases which display simple grief, which would be people whose changes in behavior and emotional state could be considered normal, according to the DSM.

Then, he checked the incidence and significance of indicators which can show the seriousness of the depressive state in both groups: symptoms of melancholia, hospitalizations, use of medications, suicidal thoughts… The result?

Both DSM-III and DSM-IV enable the differentiation of complicated grief from typical grief, but using the DSM-III diagnostic criteria it’s much easier to differentiate, and the “line” that divides them is much clearer. Whether the classification was done using the older or the newer manual, the indicators of significance of depression are present for complicated cases, however, a significant percent of cases which match the criteria of DSM-IV for complicated grief don’t display markers of “real” clinical depression.

The pharmacological industry and depression

The problems of the DSM-V aren’t limited only to depression, even though some experts have based their opinion, on mood disorders, that DSM-V will be the last version, meaning that in practice DSM won’t be utilized anymore.

Publication of DSM-III and in parallel the ICD, in 1980, was supposed to bring the end of the, then dominant, psychoanalytical method of analysis of mental disorders, and to bring in a new era of a more scientific, biological analysis of mental disorders. The expectations were that, with every new manual, diagnosis of psychiatric disorders would be more and more reliable, and the space for subjective critique and error would be smaller. Unfortunately, the trend is going completely backwards.

The APA published results of the testing of diagnostic validity of the DSM-V from which we can see that for some of the most represented mental disorders the diagnostic reliability is actually dropping. In case of depression, the kappa coefficient of agreement between clinicians for categorization of mental disorders is only 0.30 for DSM-V, for DSM-IV it’s 0.59 and for the DSM-III is 0.80. To put it simply, psychiatrists or clinical psychologists will only properly recognize and diagnose depression in only 30% of the cases.

The broadening of criteria for diagnosing depression, which is the most prevalent mental disorder, means that people that weren’t “checking all the boxes” for depression before, will now be identified and treated as clinically depressed patients. Complaints to APA about the removal of the “exception of bereavement” have fallen on deaf ears, which will cause many more people to needlessly be treated with anti-depressives. Taking in all the facts, it’s difficult not to think that the DSM-V benefits the pharmacological industry first, which is an important topic in the mental health system.

Under pressure from the public, the APA has committed to require all members of the boards that prepare and edit the manual to disclose any ties with the pharmaceutical companies – from being engaged in the testing of psychiatric medications to being an investor of a pharmaceutical company.

The results of an analysis done by a professor of clinical psychology at the University of Michigan, Lisa Cosgrove, are very devastating: most experts included in the editing and creating of the DSM have a serious conflict of interest:

  • In 3/4 of the working groups, most members have financial ties with the pharmaceutical companies.
  • The conflict of interest is most prominent in panels which define diagnostic criteria for mood disorders (depression and bipolar disorder), 87% of experts from the group for psychotic disorders, 100% of experts included in the chapters which deal with sleep disorders.