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ABSTRACT The syndrome of major depression is widely regarded as a specific mental illness that has increased to the point where it will be second in the International Burden of Disease ranking by 2020. This article examines the assumption that major depression is a specific illness, that it is rapidly increasing, and that a medical response is justified. I argue that major depression is not a natural entity and does not identify a homogenous group of patients. The apparent increase in major depression results from: confusing those who are ill with those who share their symptoms; the surveying of symptoms out of context; the benefits that accrue from such a diagnosis to drug companies, researchers, and clinicians; and changing social constructions around sadness and distress. Standardized medical treatment of all these individuals is neither possible nor desirable. The major depression category should be replaced by a clinical staging strategy that acknowledges the continuous distribution of depressive symptoms. Trials that test social and lifestyle treatments as well as drugs and cognitive behavioral therapy across different levels of severity, chronicity, and symptom patterns might lead to the development of a coherent evidence-based stepped treatment model.
DEPRESSION IS REPORTED AS the leading cause of disability burden in the developed world (Murray and Lopez 1996). It is a major cause of impaired work performance, and if left untreated a significant economic burden on society (Kessler and Frank 1997; Rice and Miller 1995). Health care systems are criticized for failing to provide even minimally adequate treatment for the majority of individuals who suffer from depression (Sanderson et al. 2003).There appears to be a belief that guideline-concordant evidence-based care will reduce the disability for all with major depression if only clinicians could be taught to deliver it effectively.
This entire edifice relies on three assumptions. First, that there is an illness called major depression that can be clearly identified. Second, that major depression has increased and is now very common.Third, that this widespread illness requires a medical solution.This paper questions these assumptions.
AN ILLNESS CALLED MAJOR DEPRESSION
Debates about psychopathology are characterized by two polarized positions. One, sometimes called "medical naturalism," assumes that mental symptoms, like bodily symptoms, are caused by disease (Pilgrim and Bentall 1999).The psychiatrist's task is to...