Depression should be managed like a chronic disease: What exactly is "depression"?

doi:10.1136/bmj.332.7550.1154-a

BMJ 2006;332:1154 (13 May), doi:10.1136/bmj.332.7550.1154-a

Letter

Depression should be managed like a chronic disease

What exactly is "depression"?

EDITOR—Scott implies that depression is always a timeless,free-standing, internally coherent, universally valid, pathologicalentity with a life of its own out there.¹ Classification systems(generally called international but in fact merely Western)provide definitions which seem to assume this. However, disclaimersin small print say in effect that diagnostic categories arenot facts of nature (as, say, a tree is) but cobbled togetherphenomena emerging as committee decisions. Indeed, it was notinevitable that depressed mood should be seen as the cardinalsymptom and name the whole syndrome. Other symptoms could havebeen used: sleep disorder syndrome or concentration and drivedisorder syndrome.

What is the evidence that depression is under-recognised andundertreated? Some might point to a few community surveys usingquantitative instruments supposedly tapping depression. Suchinstruments, with their demand characteristics and narrow focuson symptoms, generate inflated estimates of prevalence becauseof their structural inability to assess the whole person inthe context of his or her life. We do not have an epidemic ofdepression but an epidemic of antidepressant prescribing (uptwo and a half times in a decade) in an age of medicalisingand professionalising unhappiness and the problems of living.Good news for the pharmaceutical industry.²

Sociological, anthropological, philosophical, and, indeed, politicalframeworks are needed to understand properly human pain anddistress in all its nuances and ambiguities, shaped by contextand culture and above all centred on meaning (no medical modelcaptures meaning). The depression as disease model does havesome purchase (there is a subset of seriously ill people) butas a general formulation it says less about the world than thedominance of medicalised ways of seeing.

Derek A Summerfield, honorary senior lecturer

Institute of Psychiatry, Maudsley Hospital, London SE5 8AP derek.summerfield{at}slam.nhs.uk

Competing interests: None declared.

References

Scott J. Depression should be managed like a chronic disease.BMJ 2006;332: 985-6. (29 April.)[Free Full Text]
Summerfield D. Depression: epidemic or pseudo-epidemic? J R Soc Med 2006;99: 161-2.[Free Full Text]