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The age of depression
Public Interest, Wntr, 2005 by Allan V. Horwitz, Jerome C. Wakefield
Mental-health researchers have also adapted to current criteria and have much to lose if traditional measures of depression should return. Symptom-based criteria are relatively easy to use. They reduce the cost and complexity of research studies, and allow for higher research productivity. Enhanced reliability confers the appearance of a more scientific approach, although in fact considerations of validity should trump reliability. Moreover, the DSM's criteria are used in virtually all of the thousands of studies done in recent years on depression, and many researchers' careers are built around these studies. Consequently, any major reconceptualization of diagnostic criteria would throw all that into doubt. Adequately distinguishing normal sadness from depressive disorder could also possibly narrow opportunities for research funding, especially if the NIMH followed suit by focusing its efforts on true disorder. Nevertheless, as researchers certainly appreciate, reaching the goal of understanding the etiology and appropriate treatment of depressive disorder ultimately depends on using a valid definition of disorder as the basis for sample selection.
For mental-health clinicians, symptom-based measures of depression justify reimbursement from third-party insurers for the treatment of a broader range of patients than might otherwise qualify, because insurers generally will pay to treat disorders but not mere problems of living. Individual clinicians are faced every day with patients seeking help who are suffering from conditions that appear to be intense normal sadness, but that satisfy the DSM's criteria for disorder. Many private-practice clinicians will readily admit that a sizable proportion of their "depression" caseload consists of individuals who are psychiatrically normal but experiencing stressful life events. To obtain reimbursement for the treatment of such patients, the clinician must classify the individual within a DSM category of disorder, and depression is one of the more commonly used and easier ones to justify given the ubiquity of its symptoms. The result is a strange case of two "wrongs" seemingly making a "right": The DSM provides flawed criteria that do not adequately distinguish disorder from nondisorder; the clinicians, knowingly or unknowingly, incorrectly classifies a normal individual as disordered (Why should the clinician question a diagnosis officially sanctioned by the DSM?); and the patient receives desired treatment for which the therapist is reimbursed.
Such conceptually questionable diagnosis and consequent reimbursement are easily rationalized when the alternative seems insensitive and when rigid reimbursers may refuse desired treatment to people who are suffering. There are complex policy issues lurking here that would benefit from public discussion, however. In other areas of medicine, treatment of the nondisordered is openly debated: Should growth hormones be given to normal but short children? Should post-menopausal women be reimbursed for fertility treatment? When does the use of Viagra represent a medical necessity? In psychiatry, faulty criteria camouflage such treatment and allow the issue to be avoided.
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