Intended for healthcare professionals


Depression should be managed like a chronic disease

BMJ 2006; 332 doi: (Published 27 April 2006) Cite this as: BMJ 2006;332:985

What exactly is "depression"?

I'd like to commend the whole thrust of the Rapid Response to the
Scott editorial posted above by Prof David Pilgrim.This is to query the
validity and explanatory power of narrowly biomedical thinking and
intervening in the domain of human pain and distress.

Do we take it from Scott that it is settled that "depression" is
always a timeless, free-standing, internally coherent, universally valid,
pathological entity with a life of its own 'out there'? Classification
systems like ICD or DSM (generally called 'international' but in fact
merely 'Western') provide definitions which seem to assume this- though
there are disclaimers in small print to the effect that diagnostic
categories are not facts of nature (as, say, a tree is)but cobbled-
together phenomena emerging as committee decisions. Indeed it was not
inevitable that depressed mood should be seen as the cardinal symptom, and
furnish the name of the whole syndrome.Other symptoms could have been
used:"sleep disorder syndrome" or "concentration and drive disorder

Scott recycles the statement the depression is under-recognised and
under-treated. What is the evidence for this? Some might point to a few
community surveys using quantitative instruments supposedly tapping
"depression". Such instruments, with their demand characteristics and
narrow focus on "symptoms",generate inflated prevalence estimates because
of their structural inability to assess the whole person-in-life context.
We do not have an epidemic of depression, we have an epidemic of anti-
depressant prescribing (up two and a half times in a decade) in an age of
the medicalisation and professionalisation of unhappiness and the problems
of living.Good news for the pharmaceutical industry.(1)

We require sociological, anthropological, philosophical and indeed
also political frameworks for the arena of human pain and distress to be
properly understood in all its nuances and ambiguities, shaped by context
and culture, and above all centred on meaning (no medical model captures
meaning). The depression-as-disease model does have some purchase (there
is a subset of seriously ill people) but as general formulation it says
less about the world than about the dominance of medicalised ways of

(1) Summerfield D. Depression:epidemic or pseudo-epidemic? Journal of
Royal Society of Medicine 2006; 99: 161-2.

Competing interests:
None declared

Competing interests: No competing interests

03 May 2006
derek a summerfield
hon sen lect Institute of Psychiatry
Maudsley Hospital, London SE5