IT is quite clear that my grandmother is dying. Since the time of her last surgery, and no one denies this wretched detail. Now even her oncologist advises against the rigours of treatment. That there is no cure for the misery at the end of life is generally agreed. Agreed by everyone, tablets it seems, but a young and brightly efficient hospital doctor. He wants to know if my grandmother has been experiencing trouble sleeping. If she finds it difficult to concentrate. Is her appetite for food and life diminished? Does she have recurrent thoughts of death?
My grandmother is 97 and the tumour in her bowel has metastasised. Naturally, the answer to all the young doctor’s questions is yes. He moves through his checklist. After a five-minute interview, he determines that my grandmother is not, after all, experiencing the profound, normal sorrows associated with fatal illness, widowhood and old age. She has major depression disorder. He prescribes Effexor and continues his rounds.
The rhythm of this checklist and diagnosis is familiar to many. In the 2005-06 financial year, more than 12 million prescriptions for antidepressants were provided to Australian patients. Estimates suggest that 85 per cent were written by general practitioners. Using scant psychiatric training and the Diagnostic and Statistical Manual of Mental Disorders as a guide, doctors routinely pronounce us medically depressed.
Data from the Australian Bureau of Statistics indicates that one in every five Australians will have a direct experience of depressive illness during their lifetime. This epidemic could be simply read as the consequence of the “serotonin deficiency” described by the manufacturers of drugs such as Prozac, Zoloft and Paxil. According to Allan V. Horwitz and Jerome C. Wakefield, authors of The Loss of Sadness, it may also be the byproduct of an uncompromising diagnostic manual.
The DSM, published in 1952 and now in its fourth revision, is psychiatry’s most influential blockbuster. If you have visited a GP, it is likely you have been judged against its criteria. Many of us are diagnosed by a classification system based entirely on the identification of symptoms. This isolated reading of symptoms, as Horwitz and Wakefield point out, is a nosology rarely used in other kinds of medicine.
My grandmother’s cancer was neither diagnosed nor treated simply on the basis of her subjective complaint. Over months her biochemistry, her responsiveness to therapies and her medical history were examined before exploratory surgery took place. By stark contrast, her major depression disorder was diagnosed in a contextual vacuum in no time flat. There is little trace in contemporary psychiatry of Sigmund Freud’s history-taking practice.
“Of course she’s sad. She’s old, her husband’s dead and she has bowel cancer,” my mother says. The doctor prescribes nonetheless. According to the measure of the DSM IV, my grandmother is not sad. Removed from its milieu by contemporary medicine, sadness is wont to become depression.
“In the past,” the makers of frequently prescribed antidepressant Zoloft write, “people believed that depression was merely an emotional state that made people sad. These days, however, depression is recognised as a medical condition.” It was the DSM IV that facilitated this makeover of reflexive sadness into a “medical condition”. Psychiatry has abandoned its tradition of context. It is this fact more than any other that fuels the reputable rage of Horwitz and Wakefield. Depression as described in the DSM IV, they write, “fails to take into account the context of the symptoms and thus fails to exclude from the disorder category intense sadness, other than in reaction to death of a loved one, that arises from the way human beings naturally respond to major losses”.
Bereavement is the single exclusion acknowledged by the DSM IV in diagnosis of depressive disorders. In cases that do not involve the loss of a spouse or family member, sadness triggered by loss is now medicalised. Horwitz, professor of sociology at Rutgers University in New York, and Wakefield, professor in the School of Social Work at New York University, would broaden that exclusion to include other kinds of loss. Divorce, professional calamity and diagnosis of a fatal illness, they argue, can all produce the requisite two-week period of melancholy the DSM IV stipulates as a sure sign of mental illness:
In effect, these DSM definitions have become the arbiter of what is and is not considered mental disorder throughout our society. What might seem like abstract, distant, technical issues concerning these definitions have important consequences for individuals and how their suffering is understood and addressed.
Horwitz and Wakefield do not diminish the gravity of depression. In fact, they suggest, it is the one-size-fits-most definitions in the DSM that unwittingly have done so. Ironically, it is the pathologisation of normal sadness that “can be argued to have made depressive diagnosis less rather than more scientifically valid”.
Nor do the authors attempt to dismiss as malingerers depressives who might fall outside of their proposed nosology. By contrast, they mourn the vanishing of everyday sadness as it is classified and medicated into stupor. They do not propose that the divorcee, cancer patient or retrenched worker soldier on without counselling or support. But they do advocate for a therapeutic culture that recognises the purpose and value of sorrow.
Sadness may be “neither abnormal nor inappropriate” write Horwitz and Wakefield. It may even be salutary. It must always be understood within its context.
For 2 millennia, a distinction has existed between sorrow that arises with and without cause. But the DSM has eliminated the insight of Hippocrates, Freud and a “diagnostic tradition that explored the context and meaning of symptoms in deciding whether someone is suffering from intense normal sadness or a depressive disorder”.
In time for the fifth revision of the DSM, the authors suggest that at least one-quarter of patients diagnosed as clinically depressed might just be normally sad. Part of a small, determined group of clinicians and theorists who urge a new framework in the diagnosis of depressive disorders, Horwitz and Wakefield have attracted positive attention, with their work receiving favourable reviews in journals of psychology and psychiatry. Their book is bolstered by a foreword by Robert Spitzer. Decreed by The New Yorker as “one of the most influential psychiatrists of the 20th century”, Spitzer was instrumental in the development of the third DSM. The scholarship of Horwitz and Wakefield, Spitzer writes, “has caused me to rethink my own position and consider how the authors’ concerns might best be handled”.
Spitzer is in a position to make important changes to reparative theory. We, the psychiatric laity, are not. However, this academic work resonates with such common sense it’s impossible to believe that it will not positively influence those everyday “depressives” lucky enough to rifle though the right part of the self-help shelf. Although an impassioned petition to the newly appointed authors of the impending DSM V, the book functions equally well as a treatise on contemporary melancholy. This is an erudite analysis of the nature of illness. But its remit extends well beyond the realm of psychiatry.
Horwitz and Wakefield ask us to consider Willy Loman. The protagonist of Arthur Miller’s Death of a Salesman is “possibly the fictional character most representative of American life during the decades following World War II”. As Loman ages and his hopes of realising the American dream wither, he enacts the bleakest conceivable gesture. In 1949, audiences found succour in Miller’s play. Loman was seen as the dramatic enunciation of his time. Fifty years later, Robert Falls, director of the revived script, consulted psychiatrists. “They said that Willy was manic depressive, with hallucinatory aspects,” Falls told The New York Times.
Miller did not concur. “Willy Loman is not a depressive,” he said. “He is weighed down by life. There are social reasons for why he is where he is.” Miller, in the habit of great playwrights, might tie the actions of his protagonist to a cause. However, the DSM and the happiness-fixated culture that produced it allows no such mooring. Willy Loman needs a pill. This shift in the understanding of Loman, Horwitz and Wakefield write, “from a social to a psychiatric casualty represents a fundamental change in the way we see the nature of sadness”.
Eric G. Wilson, professor of English at Wake Forest University in North Carolina, is similarly eager to recoup this vanishing view of sadness. Against Happiness does not mention Miller; it does, however, reference Bruce Springsteen, William Blake and Emily Dickinson in its quest to valorise misery. Sweet sorrow, Wilson suggests, is crucial in the creation of great art. An idea that buoys every brooding, literate teen.
Regrettably, Wilson does not share Springsteen’s talent for masculine brevity. What is existence, Wilson asks, “if not an enduring polarity, an endless dance of limping dogs and lilting crocuses, starlings that are spangled and frustrated worms?” Elsewhere he writes that “our passion for felicity hints at an ominous hatred for all that grows and thrives and then dies _ for all those curious thrushes moving among autumn’s brownish indolence, for those blue dahlias seemingly hollowed with sorrow”.
If one persists with this curious fusion of Edgar Allen Poe and Gardening Australia, a rough draft of a decent argument begins to emerge: melancholy has its uses; Samuel Taylor Coleridge would never have written the few poems he did if he hadn’t been such a miserable bugger, and the current Western obsession for happiness and “wellbeing” is potentially unhealthy.
Despite his (broken) heart being in the right place, Wilson comes off like a faintly sleazy first-year English tutor whose proven method of seduction is via Sylvia Plath. Some important ideas about the understanding of happiness are drowned in vanity. And snobbishness. A great portion of this slim volume is devoted to descriptions of the author’s rustic taste in melancholy furniture and synopses of his favourite poems. One might as well visit Wilson’s Facebook page. His intention might be to rail against the medicalisation of sadness and the “grimaced grins” of an era that insists on happiness. Where he might be saying “no one understands misery”, however, he effectively says “no one understands me”.
Sally Brampton, founder of British Elle magazine, has long since reconciled with the fact of no one understanding her. Brampton, who has been diagnosed with major depressive disorder, has written a memoir that may be the subgenre’s most lucid since Andrew Solomon’s bestseller, Noonday Demon: An Atlas of Depression (2002). (Joan Didion’s The Year of Magical Thinking, 2006, does not count; remember the DSM’s “bereavement exception”.)
Shoot the Damn Dog depicts an unlikely candidate for major depressive disorder. For most of her adult life, our blonde heroine has inhabited a world of high fashion, low carbs and great success. Chic, droll and, when outside her duvet, well dressed, Brampton writes like a serotonin-deficient Carrie Bradshaw. It’s odd to think of a woman gifted of such privilege and dress sense come apart at the seams. This disjunction, in part, gives her book some punch.
Brampton describes the onset of something even Horwitz and Wakefield are likely to perceive as illness. Brampton takes us to the psychiatric ward, to several of her botched suicide attempts and, importantly, to a real sense of the stultifying indifference that characterises “real” depression. As the author forewarns, each experience of depression is distinct. Nonetheless, Brampton’s offering is bound to be of help to the well-heeled depressive.
Brampton, whose titular reference is to Winston Churchill’s infamous black dog, has some interest in the world beyond her duvet and personal recovery. Primarily, she engages with the failure of contemporary therapy to consider patient history. As such, she offers several hundred pages of her own. She must, it seems. The evolution of a patient’s sadness has become immaterial in psychiatry. For Willy Loman, for my grandmother and for anyone assessed against the criteria of the DSM IV, context is effectively irrelevant. The World Health Organisation estimates that by 2020, depression will emerge as the leading health concern of the developing world. As Horwitz and Wakefield remind us, a leading concern for the world’s clinicians is a more meticulous understanding of the disease. And the rest of us can concern ourselves with the safeguarding of our everyday sorrows.