Sadness is not a disorder

Allan V. Horwitz

is professor of sociology and dean of social and behavioral sciences at Rutgers University

Jerome C. Wakefield

is University Professor and professor of social work at New York University

In recent decades, what is meant by depression - the range of the psychiatric diagnosis - has expanded dramatically. Indeed, too much. Depression, for many doctors, therapists, and for our society at large, has come to encompass feelings of sadness that are not disorders at all.

We may be in danger of losing the notion of normal human sadness. And that would be a loss for our sense of humanity.

Consider Mother Teresa. In September, the book Mother Teresa: Come Be My Light was published. It contained letters in which Mother Teresa struggles with profound doubts about the existence of God, wrestling with desolation, emptiness and despair. Although no psychiatrist has suggested she was suffering from a psychiatric disorder, her experiences - remarkably enough - would likely qualify for a diagnosis of clinical depression according to current official psychiatric criteria.

These criteria, laid out in a handbook titled Diagnostic and Statistical Manual for Mental Disorders, or DSM for short, describing anyone who for two weeks suffers from at least five out of these possible symptoms - sadness; diminished interest or pleasure in daily activities; difficulties in sleeping or eating; physical slowing down or restlessness; fatigue; feelings of worthlessness or guilt; diminished ability to think or concentrate; and recurrent thoughts of death or suicide - can be diagnosed as having clinical depression.

Why does the person have these feelings? Judging from the DSM, that does not seem to matter. (The only exception: recently bereaved people. They are not considered depressed if their symptoms are not unusually severe or do not persist beyond two months.)

Common sense suggests that, considering her commitments in life, Mother Teresa's feelings in grappling with her doubts about God are understandable as an entirely normal and all-too-human reaction. Was she depressed - or was she simply a woman trying to do a gargantuan job and seeking some sign of divine comfort?

Early psychiatry tracts did advise professionals to distinguish the normal though painful conditions of religious guilt and doubt on one hand from psychiatric disorders on the other. Similar feelings afflict many people in response to life's various losses: departure of a loved one to war; financial difficulties; loss of a valued job; abandonment by a beloved spouse; romantic disappointment; serious illness in oneself or a loved one.

In other words, we have many good reasons for often intense sadness, and such sadness is normal, not a psychological disorder.

Considerable evidence - including scientific studies of infants and studies of cross-cultural responses - suggests that such feelings, though painful, are a normal part of human nature. They tend to moderate by themselves as time passes, as one's situation changes, or as one adjusts to it. Other studies indicate that human beings have inherited these tendencies from our primate ancestors.

Current psychiatric diagnostic criteria, however, classify much intense normal sadness as something called "Major Depressive Disorder."

The psychiatric mischaracterization of normal sadness as depressive disorder is a relatively recent development. Starting with the Greek physician Hippocrates, medicine and psychiatry for 2,500 years followed common sense in recognizing that sadness is a normal response to loss, with the same symptoms (e.g., despondency, insomnia, fatigue, restlessness) as clinical depression, but distinguishable from it by the context of the symptoms. Such symptoms were not considered disorders unless they were of a duration or severity disproportionate to their cause - or if they arose in the absence of any cause.

But that common understanding was abandoned in 1980, with the publication of the DSM-III, the third edition of the DSM, which defined depression strictly in terms of symptoms, independent of their context. This transformation in psychiatric thinking resulted not from new scientific knowledge, but from the profession's quest for clear and precise definitions of mental disorders as a foundation for scientific research.

But the desire for clear and precise distinctions doesn't mean they really exist. To distinguish normal sadness from depressive disorder, one must compare symptoms with their causes and make some extremely difficult judgments. What degree of sadness is "appropriate"? How long a period? If X just happened to me, is Y "normal" sadness? Or Y+1? Such questions are notoriously hard and may have different answers for different people. That makes diagnosis difficult and unreliable.

Whatever the scientific benefits of the DSM-III's 1980 definitions, they led to a muddying of the needed distinctions - again, distinctions that professionals had followed for millennia, in some cases - between depressive disorder and normal sadness.

The results of DSM-III's overly broad definition of depression, interacting with other social forces, have been dramatic. Since 1980, the number of people in treatment for depression has soared more than 300 percent, making depression the most commonly treated psychiatric disorder. Studies tell us that about a quarter of the population suffer from this presumed disorder at some point in their lives.

Prescriptions of antidepressant medication have likewise exploded in both general medicine and psychiatry. In the last five years alone, such prescriptions have grown from 161 million in 2002 to a projected 203 million in 2007. Moreover, a movement has begun to screen people for depression in doctor's offices and schools to identity and treat those satisfying the psychiatric definition - even when they do not define themselves as depressed or do not spontaneously seek treatment - all without reference to context and thus without adequately distinguishing normal from disordered feelings.

What is wrong with calling many cases of sadness? Can't drug treatments and psychotherapy sometimes be helpful in overcoming painful emotions that emerge after serious losses?

What's wrong is this: Depressive disorder and normal sadness are different conditions with different prognoses and implications. In responding to intense sadness, psychiatry does a disservice by confusing it with depressive disorder and thus narrowing the range of options.

Indeed, psychiatry today almost seems to deny that any sort of intense sadness can be a normal and, ultimately, even a beneficial experience.

Scientists continue to argue about exactly why evolution has seemingly designed people to feel sad when they suffer from painful events. Sadness might help us refrain from making hasty and unwise new commitments after losses; it might help mobilize sympathy from others and thus help protect us from aggressors. It may offer us a time-out to grapple with the meaning of the loss and how best to adjust to it.

Even Sigmund Freud indicated that, in contrast to the mental disorder of melancholia, the normal feeling of grief "will be overcome." He looked upon "any interference with it as inadvisable or even harmful."

True sadness often has benefits. In the end, Mother Teresa's periods of religious despair seem to have helped her identify with poor and abandoned people and helped her develop programs that improved their deplorable social conditions. Most intense sadness probably will not have such beneficial results - but we might reconsider what is lost when we unthinkingly consider the human emotions that follow loss as mental disorders.