The Right Rx for Sadness
Drugs may be an easy choice but not a good one
In the 19th-century novel Hyperion, Henry Wadsworth Longfellow admonished his hero, unlucky in love, to "take this sorrow to thy heart, and make it a part of thee, and it shall nourish thee till thou art strong again." Had Paul Flemming been real and alive today, chances are he would have taken Prozac or Paxil instead. Last month, the Centers for Disease Control and Prevention announced that antidepressants are the country's most commonly prescribed medication, accounting for 118 million prescriptions in 2005. A sign, some experts are wondering, that it's time to reassess?
Although many psychiatrists worry more about desperate souls not getting help, there's a growing concern that medicine often goes to people who shouldn't be taking it. And a consensus has formed that the estimate of how many people will develop depression at some point—1 in 6—might be greatly inflated. "There's no question that the availability of these drugs has increased the diagnosis of depression," says Jerome Wakefield, a professor of social work at New York University. Wakefield is coauthor of the new book The Loss of Sadness, which argues that selective serotonin reuptake inhibitors—Prozac, Paxil, Zoloft—are commonly overused to treat sadness, a normal and healthy response to divorce, sudden unemployment, the end of a friendship, a house foreclosure.
The problem, experts say, may be flaws in the diagnostic manual mental-health professionals use to identify depression. "We need to figure out a way to come up with depression criteria that take into account the context in which symptoms develop," contends Robert Spitzer, professor of psychiatry at Columbia University, who helped produce various editions of the Diagnostic and Statistical Manual of Mental Disorders and has concluded that it needs tweaking.
At the moment, only one such distinction is made. People grieving the death of a loved one, the manual allows, can temporarily exhibit all the signs of depression without having a mental illness. After two months, however, bereavement that lingers is classified as depression, even though mourning can go on much longer, says William Pollack, who teaches psychiatry at Harvard Medical School and is director of the Centers for Men at McLean Hospital. And severe sadness resulting from other traumas, doctors are left to conclude, must be clinical depression.
The loss factor. "We're starting to realize that it doesn't make sense to pull bereavement out of other losses," says Michael First, a research psychiatrist at the New York State Psychiatric Institute and editor of the latest DSM manual, which defines depression as five or more of a constellation of nine symptoms—ranging from depressed mood and suicidal thoughts to fatigue, insomnia, and difficulty concentrating—that last for more than two weeks. The symptoms must be severe enough to interfere with the person's social life and normal activities and should not be caused by a condition like a low-functioning thyroid.
Now, a growing body of research suggests that change is in order. Wakefield and First published a study in April that found that prolonged depressivelike symptoms are common in those experiencing broken hearts and other major life changes; after reviewing population surveys of 8,100 people, they discovered that nearly 25 percent of people who might fit the clinical definition of depression were actually showing normal signs of sadness. In 2001, about 10 percent of Manhattanites exhibited the symptoms of full-blown depression within the first two months after 9/11, according to a survey conducted by New York Academy of Medicine researchers. That was nearly twice the rate expected in a normal population. And other researchers noted an 18 percent uptick in SSRI prescriptions among Medicaid patients living near the World Trade Center during those first few months. "These people were not medically disordered," argues Wakefield. "They probably needed support more than medication."
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