Psychiatry’s Continuing Expansion of Depressive Disorder

In our book, The Loss of Sadness (LoS), published in 2007, we argued that DSM symptom-based diagnostic criteria for depressive disorder confuse intense normal sadness with depressive disorder, thus potentially misdiagnosing large numbers of individuals with a psychiatric disorder when in fact they are responding to loss or stress with normal human emotions. We detailed the many negative effects of such misdiagnosis, from unnecessary treatment to meaningless research results to distorted mental health policy. In this chapter, we review the main developments since LoS’s publication that bear on its thesis. For example, recent epidemiological surveys have confirmed that the majority of individuals experience DSM-defined depression at some point in life, antidepressant medication use continues to rise sharply, and depression is increasingly treated by general physicians rather than mental health professionals. Most importantly, the recently published fifth edition of the DSM (DSM-5) further expanded major depression by eliminating the “bereavement exclusion,” a clause that acknowledged that mild depressive symptoms could be normal when they occurred shortly after the death of a loved one. The DSM-5’s elimination of the bereavement exclusion, we find, was based on largely spurious arguments, while ample research evidence has confirmed the exclusion’s validity. In addition, DSM-5 greatly expanded the overall domain of depressive disorders by adding several new diagnostic categories that are each open to overdiagnosing the intensely sad individual as being psychiatrically disordered. The trends we observed in LoS, we conclude, are confirmed by subsequent developments and are if anything accelerating.