The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder

Here are some highlights from this 2007 book:

* The book you are about to read is a brilliant tour de force of scholarship and analysis from two of our leading thinkers about psychiatric diagnosis and the nature of mental disorders. Allan Horwitz and Jerome Wakefield’s The Loss of Sadness represents the most cogent and compelling “inside” challenge to date to the diagnostic revolution that began almost 30 years ago in the field of psychiatry. The authors begin by arguing for the existence of
a universal intuitive understanding that to be human means to naturally react with feelings of sadness to negative events in one’s life. In contrast, when the symptoms of sadness (e.g., sad feelings, difficulty sleeping, inability to concentrate, reduced appetite) have no apparent cause or are grossly disproportionate to the apparent cause, the intuitive understanding is that something important in human functioning has gone wrong, indicating the presence of a depressive disorder. Horwitz and Wakefield then persuasively argue, as the book’s central thesis, that contemporary psychiatry confuses normal sadness with depressive mental disorder because it ignores the relationship of symptoms to the context in which they emerge. The psychiatric diagnosis of Major Depression is based on the assumption that symptoms alone can indicate that there is a disorder; this assumption allows normal responses to stressors to be mischaracterized as symptoms of disorder. The authors demonstrate that this confusion has important implications not only for psychiatry and its patients but also for society in general.

The book’s thesis is of special interest to me, because I was the head of the American Psychiatric Association’s task force that in 1980 created the DSM-III (i.e., the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the Association’s official listing of recognized mental disorders and the criteria by which they are diagnosed). This was the first edition of the Manual to offer explicit symptomatic criteria for the diagnosis of each mental disorder. Now in its fourth edition, the DSM is generally considered to have revolutionized the psychiatric profession. It serves to define how researchers collect their samples, what conditions insurance companies will reimburse, what conditions courts and social agencies treat as illnesses, and how individuals themselves interpret their emotional experiences. The DSM ’s standardization of psychiatric diagnosis by using explicit rules for making a diagnosis has been critical to the explosion of research and knowledge in the mental health field. It has allowed clinicians and researchers with different theoretical perspectives, and thus different languages, to communicate with each other. It has also addressed doubts about psychiatry’s scientific status, such as concerns about the reliability of its diagnoses.

Yet the very success of the DSM and its descriptive criteria at a practical level has allowed the field of psychiatry to ignore some basic conceptual issues that have been lurking at the foundation of the DSM enterprise, especially the question of how to distinguish disorder from normal suffering. This book will bring
increased attention to these conceptual problems.

* Interventions such as grief counseling and efforts that force people to acknowledge their grief have not been shown to be very effective and can be harmful. Indeed, an alarmingly high number of grieving people worsen after receiving treatment.

* Although the permanency of the loss associated with grief distinguishes it from most other losses, grief need be no different in principle from intense sadness that arises, for example, after the unsought end of a love affair, the news that one’s spouse has been unfaithful, the dissolution of a marriage, the failure to achieve one’s cherished life goals, the loss of financial resources, the loss of social supports and relationships, or the diagnosis of a serious illness in oneself or a loved one. 40 Even the death of beloved pets or celebrities whom
one does not personally know can create periods of low mood, low initiative, and pessimism as normal reactions to loss. 41 The DSM ’s own general definition of mental disorder provided in its introduction excludes all “expectable and culturally sanctioned response(s) to a particular event, for example, the death of a loved one” from its definition of mental disorder, using grief as the prototypical excluded category. Yet, emotionally painful responses to other particular loss events such as marital, romantic, health, or financial reversals plainly can be just as “expectable and culturally sanctioned” responses as those of bereavement and should therefore fall under the definition’s exclusion as well. The criteria for MDD, however, do not follow out this logic, and they contain no exclusions for other loss responses comparable to the one for bereavement.

Marital dissolution is perhaps the most common trigger of intense normal sadness that can be severe enough to meet DSM symptomatic criteria for depressive disorder. The intense sadness that follows the loss of romantic attachments has long been a central literary theme. The double suicides of Romeo and Juliet, for example, do not result from mental disorder but from a tragic misunderstanding after the perceived loss of a lover. Other literary suicides, such as Emma Bovary’s or Anna Karenina’s, stem from realizations that the consequences of stigmatized romantic entanglements are inescapable.

Current research supports the intuition that severe losses of intimate attachments naturally lead to sadness responses: in many studies marital dissolution is more consistently and powerfully associated with depression than any other variable. Indeed, rates of depressive episodes that meet DSM criteria are comparable for persons who experience marital dissolution and those who experience bereavement. People who undergo marital dissolution are far more likely to develop first onsets of MDD over a 1-year period than people who do not.

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Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine

Here are some highlights from this 2009 book:

* Americans are besieged by advice about the efficacy of medical therapies and drugs as well as behavioral and dietary modifications that will presumably prevent disease, promote health, and extend longevity. Scarcely a day passes without revelations about new medical breakthroughs that will presumably overcome the ravages of age-old diseases. Faith in medical progress leads the United States to spend far more than any other industrialized nation on its health care system…

* Most Americans believe that their health care system is the best in the world. Yet they do not recognize the extent to which many claims about the causes of disease, therapeutic practices, and even diagnoses are shaped by beliefs that are unscientific, unproven, or completely wrong.

* For much of human history death was associated with the infectious diseases that took their heaviest toll among infants and children. Beginning in the late nineteenth century—for reasons that are not clearly understood—infectious diseases began to decline as the major causes of mortality. The reduction in mortality among the young permitted more people to reach adulthood and thus to live longer. Under these circumstances it is not surprising that long-duration illnesses—notably, cardiovascular-renal diseases and a variety of neoplasms—became more prominent elements in morbidity and mortality patterns. These diseases were associated with advancing age; the longer individuals lived, the greater the risk of becoming ill or dying from them. In one sense the increasing prominence of long-duration (or chronic) diseases was in part a reflection of the fact that more and more people were enjoying greater longevity.

To be sure, the decline in mortality from infectious diseases preceded antibiotic drug therapy. Yet the introduction of these and other drugs after World War II reshaped both medical practice and public perceptions. If infectious diseases could be conquered by antibiotic drugs, why could not long-duration diseases also be eliminated by new medical therapies? Slowly but surely Americans, for a variety of reasons, came to believe that the medical care system could play a crucial role in conquering disease and extending longevity.

* Americans remain dedicated to their health care system, as is evidenced by the fact that they continue to commit vast resources. Between 1970 and 2006 national health care expenditures increased from $75 billion to $2.1 trillion. During the same period such expenditures as a percentage of the Gross Domestic Product (GDP) rose from 7.2 to 16.0 percent. Changes in per capita expenditures were even more spectacular, rising from $356 to $7,026 in the same period. Nor were the sources of funding unchanged. During these years public funding of health expenditures increased from 38 to 46 percent.

* It is also not clear that prevailing standards of care are necessarily efficacious. The evidence in support of many widely used therapies (e.g., drugs for decreased bone density, statins for cholesterol reduction, surgery for back pain, and various surgical procedures to treat CHD) is hardly impressive, to say the least. Indeed, when the Centers for Medicare and Medicaid Services offered financial incentives to hospitals to adopt guidelines promulgated by the American College of Cardiology and the American Hospital Association to treat acute myocardial infarctions, it found that the adoption of such guidelines “had limited incremental impact on processes of care and outcomes.” Moreover, many technological innovations come into use even when there is little or no evidence that they will benefit patients. The recent introduction of CT (computed tomography) angiography is one such example. Enthusiasm for the procedure grew rapidly after the sixty-four-slice scanners came to the market in 2005. The scan exposes individuals to high rates of radiation. The Centers for Medicare and Medicaid Services became concerned with the absence of clinical evidence to demonstrate better patient outcomes. In general, patients fell into three broad categories. At one end were the “worried well,” individuals who had no symptoms of heart disease and therefore should not undergo the procedure. At the other end were high risk patients suffering from such symptoms as severe unstable angina. For them cardiac catheterization was the procedure of choice. The middle group was composed of persons who were at intermediate risk because of elevated cholesterol or blood pressure levels. n 2007 Medicare proposed to pay for CT angiography for those falling into this group who had either stable or unstable angina. These patients would be enrolled in clinical trials to determine whether the procedure was more effective than cardiac catheterization. Specialty medical societies representing radiologists and cardiologists were outraged, to say nothing about General Electric (manufacturer of the CT scanner), all of whom had a financial interest. The Society of Cardiovascular Computed Tomography (an organization of 4,700 physician members whose goal was to promote CT angiograms), the American College of Radiology, and the American College of Cardiology launched a lobbying campaign that succeeded in forcing Medicare to retract its decision even though the procedure lacked evidence of efficacy for the intermediate group and resulted as well in high costs. Nor is there conclusive evidence that CT and MRI (magnetic resonance imaging) scanning for many conditions results in improved health outcomes. Recent findings indicate that meniscal findings on knee MRIs had little clinical relevance even though those findings led to arthroscopic surgery that provided no benefit.

Equally striking is the fact that there are regional differences in both medical therapies and expenditures. Medicare patients living in Rhode Island undergo knee replacements at a rate of five in one thousand people; in Nebraska the rate is double. Female Medicare enrollees who are diagnosed with breast cancer in South Dakota have seven times the chance of undergoing a mastectomy as compared with Vermont. Age-, sex-, and race-adjusted spending for traditional Medicare in 1996 was $8,414 in the Miami region, as compared with $3,341 in the Minneapolis region.

Such differences in spending, however, are not due simply to regional differences in the prices of medical care, differences in disease prevalence, or socioeconomic status. The evidence strongly suggests that such differences are a function of the more inpatient-based and specialist-oriented pattern of practice that prevails in high-cost regions. Neither quality, access to care, nor outcomes are superior in such regions. Indeed, the more hospitals, physicians, laboratories, and subspecialists in a given geographical area, the more they are used. An examination of Medicare spending and outcomes of care for hip fracture, colorectal cancer, and myocardial infarction found that persons in high-spending regions received 60 percent more care but did not have better quality or outcomes of care. In the 306 Hospital Referral Regions (HRRs) in 2003, the incidence of hip and knee replacement for chronic arthritis and surgery for low-back pain varied from 5.6- to 4.8- and 5.9-fold, respectively, from the lowest to the highest region.

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Historicism and Hill Street Blues, Major Depressive Disorder, Afghan Refugees

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Health beliefs (8-19-21)

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Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine

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22:00 Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine, https://www.amazon.com/Diagnosis-Therapy-Evidence-Conundrums-American-ebook/dp/B0037CFD8C/

* “For much of human history death was associated with the infectious diseases that took their heaviest toll among infants and children. Beginning in the late nineteenth century—for reasons that are not clearly understood—infectious diseases began to decline as the major causes of mortality. The reduction in mortality among the young permitted more people to reach adulthood and thus to live longer. Under these circumstances it is not surprising that long-duration illnesses—notably, cardiovascular-renal diseases and a variety of neoplasms—became more prominent elements in morbidity and mortality patterns. These diseases were associated with advancing age; the longer individuals lived, the greater the risk of becoming ill or dying from them. In one sense the increasing prominence of long-duration (or chronic) diseases as in part a reflection of the fact that more and more people were enjoying greater longevity.

* During the latter half of the twentieth century, however, a dramatic perceptual transformation took place. Nowhere was this better expressed than in the constitution of the World Health Organization, promulgated in 1946 and ratified in 1948. “Health,” the constitution stated in its declaration of principles, “is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.” Such a definition implied new roles for the medical profession. The care and treatment of the sick and infirm remained part of the physician’s responsibility. But to this were added the functions of making people healthy, happy, and socially adjusted.”

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