The Medicalization of Depression
The Medicalization of Depression
The Diagnostic and Statistical Manual of Mental Disorders
It is estimated that 350 million people around the world suffer from depression and by 2020 it would be the second leading cause of disability worldwide [1].The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), describes Major Depressive Disorder (MDD) as a low mood, a loss of interest in daily activities, or feelings of worthlessness for more than two weeks. To qualify for a diagnosis of clinical depression, a patient must experience at least five of the following symptoms nearly everyday for more than two weeks[2]:
| Diagnostic Criteria for Major Depressive Disorder: DSM-5 |
|---|
| 1) Depressed mood most of the day, indicated by subjective feelings or observation made by others |
| 2) Significant diminished interest or pleasure in all or almost all activities |
| 3) Significant weight loss when not dieting or weight gain, or increase or decrease in appetite |
| 4) Insomnia or excessive sleepiness |
| 5) Psychomotor agitation or retardation |
| 6) Fatigue or loss of energy |
| 7) Feeling of worthlessness or excessive guilt |
| 8) Diminished ability to think or concentrate |
| 9) Suicidal thoughts |
Medicalisation of Depression
The medicalisation of depression categorised clusters of symptoms and behaviours for the purpose of diagnosis and treatment. This has brought greater clarity and objectivity for clinicians, researchers, and patients when diagnosing and managing depression. It helped establish greater consistency for what clinical depression encompasses [3]:. Furthermore, it allow individuals to become more aware, if and when symptoms manifest and to bring greater ability to monitor risk factors.
However, when misused, the medicalisation of depression can become a process of turning non-medical conditions (such as normal fluctuations in emotions) into ones that require clinical treatment. Sadness that is being wrongly medicalised will cause false-positive patients to go through unnecessary treatments, emotional trauma, and side-effects for a diagnosis that they’ve been wrongly assigned [4]:.
Furthermore, the fulfilment of the objective symptomatic manifestation of the DSM-5 criteria listed above does not equate to a condition that require medical intervention. Therefore, the benefits of the classification system of depression is widely debated. From a sociological perspective, health authorities such as the APA and WHO are conferred with the ability to socially and medically define what healthy emotions as opposed to unhealthy ones entails. As such, given the ever growing list of diagnosis added to the DSM, it brings many to question whether any prolonged negative emotion could be medicalised as a mental illness. It has been argued that the classification system has been useful for public health policy makers, insurance companies, politicians, and pharmaceutical companies who needs statistically significant populations and data to back their agendas [5]:. However, the benefits of the classification system is yet to be understood by many patients.
Medical or Cognitive approach for Depression?
Medical Approach
Further complicating the subject, depression can have a combination of biological, social, and cognitive basis. However in training and practice, treatment for depression are often based on the medical or cognitive approach. The medical approach views depression from: a biological basis - using a cause-and-effect perspective (ie. a chemical imbalance causes depression), as such, it requires a direct solution to fix the problem. Patient often take on a passive role when undergoing the medical treatment of depression and they are only required to follow the medical guidelines to take the prescribed dosage of the drug given. Therefore the responsibility of the cure falls externally to the patient — the drug will deliver the cure.
Cognitive Approach
On the other hand, a cognitive approach views depression as a condition that requires mental intervention. The solution varies person by person and is often tailored specifically for the patient’s subjective needs. Furthermore, given the cognitive basis of depression (as opposed to biological), the patient and physician will both play an active and collaborative role in setting and achieving their goal. Therefore the responsibility of the cure falls on both the patient and physician. As opposed to the medical approach of depression, which is solution focused, the cognitive approach is process oriented and often take a longer course of treatment.
Medical & Cognitive combined
Although both approaches are important in treating depression, and a combination of the two often lead to higher rates of success, the medical approach is often the preferred model and it is widely used as the first-line of treatment by healthcare providers. Despite the chronic nature of depression, government funded healthcare providers often treat depression using the one-off medical approach. This can cut a significant amount of time and cost required in counselling services or cognitive-psychotherapies [6]:. However such an approach takes on a reductionist perspective of depression and it aims to ‘fix’ human emotions through drug consumption whilst ignoring the impacts of culture, cognition, and education.
The role of pharmaceutical companies
Recent research has revealed that over half of the DSM-5 panel members have financial ties with the pharmaceutical industry. Consequently, panel members have direct or indirect vested interest in expanding the definition of depression [7]:. Consequently, physicians are able to prescribe medication for an expanding population of eligible patients. It is noteworthy to mention that, there is ample research to suggest that, although the population of people affected by depression has remained stable, given the expanding number of symptoms included in the DSM, the number of diagnosis has been on a rise. Furthermore, prescriptions for antidepressants has risen more than 270% in the US between 1996 - 2005 [8]:.
Bereavement and depression
One of the most controversial update from DMS-IV to DMS-5 was the inclusion of bereavement as a criteria for major depressive disorder. Bereavement is defined as a profound sense of grief over a major lost in life, such as the death of a loved one. Many argue that the inclusion of bereavement is an overstep in pathologizing normal emotions that is necessary for the grieving process. Furthermore, a MDD diagnosis can give physicians the power administer treatments or for law enforcement authorities to retain custody of their children. Therefore a diagnosis is not just a label. It also carries both social and legal power.
Conclusion
Emotions are a normal part of the human experience. However, the medicalisation of sadness, such as bereavement not only prevents healthy emotional regulatory functions from operating [9]:, it also stigmatise and unnecessarily pathologize adaptive emotional experiences [10]:.
References
- ↑ World Health Organization. (2007). International statistical classification of diseases and related health problems (10th rev.). Geneva, Switzerland: World Health Organization.
- ↑ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- ↑ Aneshensel, C. S., & Phelan, J. C. (1999). Handbook of the sociology of mental health. New York: Kluwer Academic/Plenum.
- ↑ Dowrick, C., & Frances, A. (2013). Medicalising unhappiness: New classification of depression risks more patients being put on drug treatment from which they will not benefit. Bmj, 347(Dec09 7). doi:10.1136/bmj.f7140
- ↑ Appignanesi, L. (2011). The mental illness industry is medicalising normality | Lisa Appignanesi. Retrieved November 10, 2016, from https://www.theguardian.com/commentisfree/2011/sep/06/mental-illness-medicalising-normality
- ↑ Rothman, D. J. (1971). The discovery of the asylum: Social order and disorder in the new republic. Boston: Little Brown.Page 63
- ↑ Kaplan, A. (2009, January). DSM-V controversies. Psychiatric Times, 26(1). Retrieved from http://www.psychiatrictimes. com/display/article/10168/1364926
- ↑ Olfson, M., & Marcus, S. C. (2009). National patterns in antidepressant medication treatment. Archives of General Psychiatry, 66, 848–856.
- ↑ Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depres- sive disorder. New York: Oxford University Press.
- ↑ Busko, M. (2008). Bereavement-related depression identical to other depression types: DSM-IV exclusion for bereavement should be revised. The American Journal of Psychiatry, 165, 1373–1375.