Tossing “Major Depression” Over the Side

Psychiatry hasn’t seen anything like this since the ridiculing of psychoanalysis began in the 1970s that was to lead to the replacement of Freud with neuroscience. Key pieces of belief in the field have now become objects of frank incredulity. And because these big chunks of belief, such as “major depression,” have billion-dollar price tags attached to them, the stakes are enormous.

“Major depression” was created in 1980 in DSM-3 as the main kind of depressive illness. It collapsed psychiatry’s two previous depressions – endogenous depression (serious) and reactive depression -- into one entity and ended the age-old distinction between melancholia and the package of anxiety and dysphoria that used to be called “nervous illness.” Collapsing the two was a historic blunder but few noticed. Everyone was so glad, with DSM-3, to get out from under the yoke of psychoanalysis.

But now, forty years later, people are noticing. And a recent rocket was sent up by Gordon Parker, professor of psychiatry at the University of New South Wales in Sydney, in the current issue of the Acta Psychiatrica Scandinavica, which despite its regional-sounding title, is becoming the hot new journal in psychiatry. “A long-standing concern from its inception in DSM-3,” said Parker, “is the positioning of ‘major depression’ as if the concept is a meaningful homogeneous entity.” (Parker, 2014)

This is not the first time Parker has criticized major depression as a highly heterogeneous, artificial construct. But this time his comment evoked embarrassed agreement rather than screams of rage. Jan Fawcett, at the University of New Mexico School of Medicine, the chair of the Mood Disorders work group of DSM-5, replied, somewhat defensively, that despite their better judgment the committee had felt compelled to wave “major depression” through because the American Psychiatric Association had set up a Scientific Review Committee (SRC) to watch hawk-like over any change in their beloved DSM, and that “the reason for changes and a discussion of possible unintended negative consequences, had to be submitted to the SRC and be given a ‘passing score’ to be included in DSM-5. This lead to a conservative approach to changes and . . . the inability to make ‘wished for’ changes.”

This is a stunning confession. It meant that members of the work group had intended to dismantle major depression, but did not have the courage to go up against the menacing SRC. Fawcett is saying this in print? He ended his reply, “So, OK, maybe the whole concept of DSM definitions of psychiatric disorders is obsolete – maybe it has served its purpose, and now it is time to move on.” (Fawcett, 2014)

I rubbed my eyes when I read this. One of the DSM insiders has just announced that the entire process is bankrupt, lacking in credibility, and scientifically useless.

The Nosological Rebels, this group of senior psychiatrists who cannot stomach the DSM mishmash and want true diagnoses that “cut Nature at the joints,” brought out the knives.

One of the Nosological Rebels, a senior figure at a major American psychiatry department, said, “Reading Dr Parker’s discussion of the nuances of the various mood disorders, I felt something like the nostalgia one feels meeting up with old friends. You don’t hear that kind of talk much these days, at least not in the environs of [blank]. The topics go to the latest neuroscience paper or treatment scheme.” This senior figure said that Fawcett “seems to have missed the point that the great lumping [of major depression] in the DSMs likely has something to do with why they can’t find anything. Is there something that explains why psychiatry, the most clinical specialty in medicine, fled the clinic? When I read things like Dr Fawcett’s reply, I think of cardiologists without stethoscopes, neurologists without reflex hammers, or blind dermatologists.” Psychiatrists can’t find anything because they have this hopelessly inadequate guide to show them the path.

I think these are early days. Fury is building against DSM and against the American Psychiatric Association for having foisted this compendium of error, blunder and myth onto the field. What is needed now is for some other agency, such as the Karolinska Institute in Stockholm or the National Institute of Mental Health in Bethesda, to take over the job of classifying illnesses and to start from ground zero. Until then, patients have a substantial risk of being misdiagnosed and mistreated.