Complicated vs. uncomplicated and some depressing levels of innumeracy

Furious Seasons recently reported the publication of a paper in the Archives of General Psychiatry, in which the authors argue, based on epidemiological data, that the current practice of disqualifying the recently bereaved from a diagnosis of Major Depressive Disorder should be extended to people who have recently suffered other types of losses, which would result in a reduction of the currently accepted lifetime prevalence rate of Major Depressive Disorder by 25%. This has caused quite a splash, resulting in media coverage in the New York Times, much blog commentary and mass mail-outs to every critical psychiatry / consumer group email list. (And for the non-mathematicians out there, saying that the 'official' lifetime prevalence of depression should be cut by 25% is equivalent to saying that it has been overstated by 33%, not 25% as reported, which should get everyone even more excited. Who said maths wasn't useful for anything? Number up!)

I've read the full paper, and it does confirm the common sense notion that sadness resulting from life traumas should not be considered categorically different than the sadness resulting from bereavement. But it does rely on making a distinction between 'uncomplicated' vs. 'complicated' depressive reactions. Which is fair enough from a scientific point of view, since DSM only considers 'uncomplicated' bereavement to exclude a patient from receiving an diagnosis of Major Depressive Disorder, and it is this 'uncomplicated' exclusionary space that the authors seek to have expanded to include 'uncomplicated' reactions to other losses or stressful events. But in spite of enabling the authors to re-calculate the lifetime prevalence of depression as 11.3% (originally reported as 14.9%), the feeling the paper left me with was of a 'soft' result (necessarily constrained by research protocols) that does not actually pose much of a challenge to the ideology masquerading as science that underpins the conceptualisation and diagnosis of depression.

'Complicated' episodes, whether triggered by bereavement or other forms of loss, were distinguished by the authors from 'uncomplicated' episodes by the existence of at least two of the following: morbid preoccupation with worthlessness, suicidal ideation, marked functional impairment (not being able to work or socialise) or psychomotor retardation, prolonged duration (> 12 weeks) or a suicide attempt. Such 'complications' would enable a diagnosis of depression regardless of any precipitating factors.

I think most of us would agree that someone suffering from at least two of the above might benefit from (and indeed require) some kind of intervention, although those of us who have been damaged and marginalised by the excessive emphasis that mainstream psychiatry places on biogenetic causes would have to seriously question whether psychiatric interventions would be of any use. I doubt that as a result of this paper, mainstream psychiatry will ever stop to consider whether the concepts of 'disease' and 'disorder' are still out of place even in 'complicated' responses to bereavement and other losses, and to begin to think in terms of 'injuries' instead. As the authors point out, false-positive diagnoses can lead to stigmatisation, but even 'true-positive' diagnoses could be reframed in a less stigmatising way.

Needless to say, it should come as no surprise that three out of the four authors of this paper are social workers, not psychiatrists.