Should screening for depression among children and adolescents be demedicalized

One of the most fundamental questions in psychiatry regards the distinction between mental disorders and normal, albeit painful and undesirable, human functioning that presents a ‘‘problem in living.’’ Mental disorders are conditions in which something has gone harmfully wrong with the functioning of some biologically designed mental process or mechanismVa harmful dysfunction. In contrast, normal psychological processes in response to life’s vicissitudes often give rise to intense negative emotions or other negative conditions. These distressing emotions might warrant professional support or intervention, but they have different prognoses and open up a different range of options for intervention than do disorders. Our book, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder, argues that the current DSM definition of major depressive disorder (MDD) does not validly distinguish problematic, but natural, human emotions in response to loss and stress from depressive disorders. For example, people who have symptoms of just 2 weeks of depressed mood, diminished pleasure in usual activities, insomnia, fatigue, and problems in concentrating meet the MDD criteria, yet this sort of reaction can naturally occur in response to many major losses in life. Although the definition contains an exclusion for uncomplicated bereavement, it does not exclude responses to other major losses, such as the dissolution of a marriage, the loss of one’s job or retirement fund, or a terminal medical diagnosis. The result, we claim, has been to pathologize normal emotions because of a failure to place the ‘‘symptoms’’ of intense sadness in the context of life events. We did not questionVand in fact affirmedVthat genuine depressive disorders exist, are serious and sometimes life threatening, and urgently need attention. Nor did we question that good clinicians can go beyond the current diagnostic criteria and use information about the context of symptoms to judge whether a condition with depressive symptoms is normal or disordered. Rather, we questioned the validity of the current diagnostic criteria in drawing the distinction between intense normal responses and medical disorders. Separating normal sadness from depressive disorder and placing emotions in context is especially difficult and important among adolescents. Levels of negative affect in response to stressful events are extraordinarily In Context is a venue for scholarly contributions from experts on scientific, social, political, and cultural issues pertinent to children’s mental health. In Context presents topics that do not immediately fall under the purview of scientific research or clinical practice but that nevertheless affect the lives and mental health of children. Its goal is to educate clinicians and researchers, to encourage discussion, and to foster interdisciplinary collaboration. Accepted January 22, 2009. Dr. Horwitz is Dean of Social and Behavioral Sciences at Rutgers University. He is, with Jerome Wakefield, the author of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Dr. Wakefield is University Professor, Professor of Social Work, and Professor of Psychiatry at New York University, and the author of many articles on psychiatric diagnosis and the concept of mental disorder. He is coauthor with Allan Horwitz of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Correspondence to Allan Horwitz, Ph.D., Rutgers University, Sociology and Health Institute, 77 Hamilton Street, New Brunswick, NJ 08901-1248; e-mail: avhorw@rci.rutgers.edu. 0890-8567/09/4807-0683 2009 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e3181a5e3ad I N C O N T E X T Schuyler W. Henderson, M.D. Assistant Editor