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."
But primary-care physicians, who diagnose and treat the vast majority of depression cases, may be hard pressed to tease out the origin of symptoms during a quickie 10-minute physical. And without a blood test or brain scan for depression, doctors often rely on standard screening questionnaires to measure the symptoms themselves—which, like the DSM manual, don't consider the context in which they occur. The forms also don't take into account the impact that symptoms are having on a person's functioning, says Spitzer. That information would help indicate whether grief is progressing into a mental disorder.
Even when a life circumstance is found to be the culprit, doctors may be reluctant to refer patients to grief counselors or psychotherapists for emotional support. That's because managed care doesn't reimburse generously for therapy that entails more frequent and longer office visits, says Carolyn Robinowitz, president of the American Psychiatric Association. About 65 percent of employee health plans put a cap on the number of mental health visits, according to Kaiser's 2006 survey of employer health benefits. And plenty of therapists don't accept insurance.
So what doctors often choose to do is write prescriptions. "It's the easy solution, especially when patients demand a quick fix," says Ellen McGrath, a psychologist in New York and author of When Feeling Bad Is Good. A 2005 study published in the Journal of the American Medical Association found that 55 percent of volunteers posing as patients with a few depression symptoms received a prescription for Paxil after saying they saw it advertised in a commercial; just 10 percent of those who did not ask for any antidepressants walked out with a prescription. Study leader Richard Kravitz, a professor of medicine at the University of California-Davis, says drug companies encourage this trend by bombarding consumers with ads that do not make enough of a distinction between sadness and depression.
But antidepressants are no panacea. While helping some sad folks numb the pain, they are known to tamp down joyous feelings, too. After being diagnosed with cancer several years ago, Barbara Kline of Corrales, N.M., sought antidepressants to help manage her fear of the disease and shock at having her professional life come to a grinding halt. But the 58-year-old public relations executive also found she wasn't able to feel any stirrings of pleasure—even from the masseuse who regularly came to her house. She decided to go off the meds after just four months. "I wanted to examine my feelings and then make something out of them," she says, which inspired her to start a cancer patient support group.
There are also side effects to consider. As many as 60 percent of SSRI users experience such sexual problems as decreased libido and erectile dysfunction, and about 25 percent have sleep difficulties, according to an April 2006 report published in the Cleveland Clinic Journal of Medicine. Young adults and teens face a slightly increased risk of suicidal thoughts during the first month of treatment, and new research suggests elderly users are at risk of accelerated bone loss.
Getting through. Some experts also believe that medicating normal sadness could delay the healing process. "I'd always worn the busy mask, denying sadness, pretending I was happy," says Mark Linden O'Meara, who tried antidepressants without success to get over the deaths of his parents and severe financial troubles. "The drugs gave me headaches and made me feel so numb." The 49-year-old writer from Burnaby, British Columbia, says it took a long crying jag after a romantic breakup to help him finally start acknowledging the pain of his losses from years earlier. "As I released the emotion, I was eventually able to start laughing and enjoying life more."
Designed to repair malfunctions of biochemical pathways in the brain, antidepressants aren't supposed to address the psychological source of sadness. "When antidepressants are given to those in mourning, their symptoms may go away, but they don't feel good," says Pollack. In some cases, though, medications can be vital: when grief intensifies to the point that someone, say, hallucinates or loses touch with reality. Or when a sad person gets stuck and moves into depression.
In most cases of sadness, feelings of anguish dissipate with enough time to process them. McGrath recommends a "feel, deal, heal" approach. She advises clients to acknowledge the depth of their despair and identify what triggered the feelings, then share the feelings with a close friend, family member, or therapist. As the sadness starts to lift, they integrate the episode into their life and appreciate how it has made them stronger. "So much of our society still feels [sadness] is a problem to be gotten rid of rather than understood and supported," Pollack says. Being open to the full complexity of human emotions, he adds, yields not just sadness but genuine happiness, too.