Satel reviews The Loss of Sadness (Reiner)

Sally Satel has written an excellent review of Horwitz & Wakefield 's recent book, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder.  The review is published in the Feb 27th edition of the New Republic, but for those without a subscription, Powell's Books has posted it for free on their website.  There is much to recommend in both Satel's extensive review and Horwitz & Wakefield's book; especially relevant for the neuroethics crowd is the book's exhaustive treatment of the route by which psychological variations from the mean become codified into disease in successive editions of DSM.  As Satel points out,

"The Loss of Sadness comes at a fortuitous time for American psychiatry. The APA has just selected the hundreds of clinicians and scientists who will develop the DSM-V. They would be wise to consider the work of Horwitz and Wakefield, and their demand that we avoid pathologizing normal reactions to the vicissitudes of life. Normal reactions to timeless human heartache are not the same as mental disorders. Horwitz and Wakefield call for changes to major depressive disorder that would exempt patients whose depression is triggered by a serious loss, just as bereaved patients are ineligible for the diagnosis. This is certainly worth considering."

The issues that Horwitz & Wakefield raise are hardly confined to the fuzzy line that has been drawn between sadness and depression.  The Loss of Sadness is a clarion call to all who think incisively about what constitutes disease in the context of behavior.

Comments

[Patrick S. O'Donnell]

Indeed, important stuff: and thanks for the link to the free online review. I think the Crews review essay from NYRB nicely complements this: http://www.nybooks.com/articles/20851 (And there is an exchange of letters in the Feb. 14th issue).

[teddydouglas]

The pertinent issue here is not the label of "Disorder", but whether we can treat it and improve the client's quality of life. Ordinary sadness triggered by loss may not be abnormal or indicative of disease per se, but if we as psychologists have tools that can help this person we would be remiss to dismiss the case.

The suggestion by Horowitz and Wakefield to "exempt" loss-triggered sadness from the DSM-V definition of depression will probably do more harm than good. Though such clients may not be suffering psychiatric illness, they may still benefit from professional intervention. And since insurance companies often refuse to cover treatment when there is no "labelable" illness, such people will effectively be denied much needed relief.

[Patrick S. O'Donnell]

But what if such sadness does not call for "treatment"? And what if it's a dangerous assumption or presumption to think treatment of any sort really amounts, in the end, to an improve[ment] [in] the client's quality of life?" [I suspect Freud had a more modest or circumspect goal in mind.] See, for instance, the "argument" in Eric G. Wilson's Against Happiness: In Praise of Melancholy (2008) For a summary, see: http://www.latimes.com/news/opinion/sunday/commentary/la-op-wilson17feb17,0,5045522.story

Or what if one's family and friends, or one's rabbi or priest or Buddhist teacher are better situated to help one "work through" such sadness (which, provided it's not symptomatic of mental illness, may be part and parcel of the human condition)? What *if* the experience of sadness provides a unique opportunity for the kind of self-examination and self-reflection that is intrinsic to growth in human awareness and psychological development? Does one necessarily require a psychiatrist or psychologist to, as it were, look within, to engage in the forms of personal self-scrutiny long familiar to certain philosophical and religious traditions? Conversely, an increased understanding among non-professionals of the symptoms of mental illness may allow us to see when others are not the best judges in their own case (I grant, in other words and with S. Nassir Ghaemi, that 'determining what is healthy for oneself may be distorted by conditions in which insight is absent, such as manic depression.')

Furthermore, the "talking therapy" that *might* serve as the best form of psychological intervention is far too expensive to be routinely approved by the insurance industry in any case. Reliance on DSM diagnostic criteria seems to result in a default deference to a psychopharmacological approach to the relief of the episodic occurrence of suffering. Perhaps even "philosophical counseling" provides a cure of sorts to what ails us. Cf.: http://www.parapsi.com/phil-guidelines.html

At any rate, I think it's healthy to attempt to see this subject from different and perhaps conflicting perspectives that do not assume a "medicalization" of sadness or indeed of other forms of difficult emotional experience. I do think there is a very real danger in pathologizing everyday depression or in what Peter Kramer has called "cosmetic psychopharmacology," although I don't thereby deny that some forms of depression (e.g., manic depression) are rightly understood as falling within the rubric of "mental illness."