The New York Times
April 3, 2007
By BENEDICT CAREY
About one in four people who appear to be depressed are in fact struggling with the normal mental fallout from a recent emotional blow, like a ruptured marriage, the loss of a job or the collapse of an investment, a new study suggests. To avoid unnecessary diagnoses and stigma, the standard definition of depression should be redrawn to specifically exclude such cases, the authors argue.
The study, appearing today in The Archives of General Psychiatry, is based on survey data from more than 8,000 Americans; it did not analyze the number of people who had been misdiagnosed.
Psychiatrists and other doctors who take careful medical histories do so precisely to rule out such life blows, as well as the effects of physical illnesses, before making a diagnosis of depression.
But the American Psychiatric Association’s diagnostic manual does not specifically exclude people experiencing deep but normal feelings of sadness, unless they are bereaved by the death of a loved one. And an increasing number of school districts and health clinics use simple depression checklists, which do not take context into account, the authors said.
“Larger and larger numbers of people are reporting symptoms on these checklists, and there’s no way to know whether we’re finding normal sadness responses or real depression,” said Jerome C. Wakefield, a professor of social work at New York University and the study’s lead author.
His co-authors were Mark F. Schmitz of Temple University, Allan V. Horwitz of Rutgers University, and Dr. Michael B. First, a psychiatrist at Columbia who edited the current version of the psychiatric association’s diagnostic manual.
The study’s findings suggest that previous estimates of the number of Americans who suffer depression at least once during their lives — more than 30 million — are about 25 percent too high.
Dr. Darrel Regier, director of research for the American Psychiatric Association, said, “I think the concern this study raises is real, and that we do need to be very careful not to overdiagnose a normal, homeostatic response to loss and call it a disorder.” But he added that depression checklists had in fact helped identify people in need of treatment.
The researchers analyzed responses from 8,098 adults to survey questions posed between 1990 and 1992. The questions were based on diagnostic criteria for mood problems and asked people who reported a period of sadness if they remembered any event that might have caused it, like the death of a loved one or a divorce.
The diagnostic manual makes a distinction between severe bereavement that precipitates lasting depression, which is rare, and normal grief, which looks like depression but usually loosens its hold in a few weeks or months.
The researchers found 56 people in the survey who suffered this normal reaction after the death of someone close. Another 174 people struggled with normal levels of distress after a different kind of blow, like the breakup of a relationship or a lost job — a group that would qualify for a diagnosis of depression under the current definition.
The investigators then compared the two groups’ answers to questions about nine kinds of depression symptoms, including a loss of appetite, sleeping problems and thoughts about suicide. The only significant difference, they found, was that those grieving a death were twice as likely as those digesting another kind of loss to have thoughts about death or suicide.
“The profile you get for these two groups is so very, very close,” Dr. Wakefield said, that it does not justify the exclusion of one group and not the other in the depression diagnosis.
The authors draw no conclusions about the study’s implications for treatment. Doctors often treat even normal grief reactions if patients are in some pain. But such patients should not be identified as having depression, the authors conclude.