Allan Horwitz and Jerome Wakefield -- The loss of sadness
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Also see my reviews of the following:

- Jeffrey A. Lieberman -- Shrinks: The untold story of psychiatry

- Gary Greenberg -- The book of woe

There is so much to think about in this book; it's overwhelming.
Some of the main issues discussed are:

- Can psychiatric diagnoses be done reliably?  That is, can those
  diagnoses be consistently repeated?

- Can psychiatric diagnoses be valid?  That is, does a psychiatric
  diagnosis of a particular disorder identify an underlying cause or
  something that can be treated.

- Are we, for example in the U.S. or in the U.K. over-diagnosing
  depressive disorder or abnormal sadness?  Are we labeling the
  normal sadness that someone exhibits after a loss or setback as a
  disorder, as something that needs treatment, even as something
  that calls for medication?

Horwitz and Wakefield go into much detail explaining why and how
they think the over-diagnosis of abnormal sadness has occurred.
Some of the causes they suggest are: (1) During the revision process
that created DSM-III, there was a heavy emphasis on identifying and
listing *symptoms* that could be used to determine whether a person
has a psychiatric disorder or ailment and which particular disorder
that person has.  But, that emphasis on symptoms leads, Horwitz and
Wakefield contend, to ignoring underlying causes, i.e. to ignoring
what Horwitz and Wakefield call etiology.  And, because we ignore
causes, we label the sadness that is an appropriate response as a
disorder.  (2) The social sciences have encouraged us to have
attitudes of cultural relativism.  And, because some cultures
tolerate and label as normal or even admirable different levels of
sadness, we are led to feel that it's up to us to decide how much
and what level and what length of time is normal or abnormal for
sadness.  In other words, we can label as normal or as abnormal any
level of sadness that we choose.  (3) And, of course there is the
possibility, Horwitz and Wakefield suggest, that the medical
insurance providers and the pharmaceutical industry have encouraged
or discouraged the diagnosis of more or less sadness as being in
need of treatment and medication because it is in their (insurance
and pharmaceuticals) financial interest to do so.

Horwitz and Wakefield worry about an "over expansive" definition of
sadness, one that labels too many people as ill, dysfunctional, and
in need of treatment.

What if, instead of talking about illness, dysfunction, and
disorder, we talk about those who want help and guidance to make
their lives better and (since we are discussing sadness) happier.

We have to ask ourselves who is helped and who is harmed by the use
of symptom-based criteria to label individuals depressed and
suffering from disorder?  I'm less worried when we are talking about
those who are seeking help; I'm more worried when people are
diagnosed as disordered and in need of treatment whether they want
it or not.  However, this is *not* a simple issue.  There are those
in our society who resist taking their psychotropic medications,
often for real reasons (e.g. because of their side-effects), but
when they do, they become harmful and even dangerous to themselves
and to those around them.  It's because of situations like this that
we need Horwitz and Wakefield to remind us about and make us think
through the issues surrounding psychiatric diagnoses.

What about those of us who may not be abnormally sad and to whom it
is not accurate to say that they have a depressive disorder, but who
are consistently sad and down.  Someone who suffers from long-term
unhappiness with no apparent cause deserves help.  Perhaps their
unhappiness does not lead them to suicide or even less harmful
actions, but many of us feel that they also need help.  Some of
these may try to improve their mood through the use of medication,
some might drink alcohol, some might even turn to religion.  I'm one
of those who feels that any of these can be helpful, and any of them
can be damaging.  Perhaps, a diagnosis of sadness or depression can,
in some cases, be helpful, if it leads to awareness, and can, in
some cases, be harmful, if it leads to over use of medication, to
abuse of alcohol or other drugs, to fanatical religion, etc.

Many of us want happiness of some form or another.  In the U.S., the
right to "the pursuit of happiness" is even written into our
"Declaration of Independence".  So, why would we not want to be able
to avoid sadness and seek happiness in a variety of different ways.
I suspect that Horwitz and Wakefield would not object to that, but
would object to encouraging any of us to do so without awareness,
without consideration of the consequences and alternatives, and
without addressing possible real causes of that sadness.

One worry is over-medication.  But, is that worry any greater than
concerns about the excessive use of drugs, alcohol, caffeine, etc?
Maybe what we need to get used to and to remember is that the use of
drugs is always in need of caution, whether those drugs have the
approval of a psychiatric professional or not.  And, it should be
obvious that prescribing psychotropic drugs to children is about as
close to legally giving alcohol to minors as you can get.  As
always, powerful drugs means the power to do much harm.

Horwitz and Wakefield have a definite stand on whether we
over-diagnose sadness as a disorder: they believe we do diagnose too
many people as having a depressive disorder of some kind and they
argue strong and long for that position.  Those arguments are very
informative and well thought out.  You may agree or disagree with
those arguments.  But, in either case, you will find much in this
book to inform and help with your own thinking about sadness and
depression in particular, and psychiatry and psychology and mental
disorder in general.

07/10/2015

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