What do you think?
Rate this book
The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder
Depression has become the single most commonly treated mental disorder, amid claims that one out of ten Americans suffer from this disorder every year and 25% succumb at some point in their lives. Warnings that depressive disorder is a leading cause of worldwide disability have been accompanied by a massive upsurge in the consumption of antidepressant medication, widespread screening for depression in clinics and schools, and a push to diagnose depression early, on the basis of just a few symptoms, in order to prevent more severe conditions from developing.
In The Loss of Sadness, Allan V. Horwitz and Jerome C. Wakefield argue that, while depressive disorder certainly exists and can be a devastating condition warranting medical attention, the apparent epidemic in fact reflects the way the psychiatric profession has understood and reclassified normal human sadness as largely an abnormal experience. With the 1980 publication of the landmark third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), mental health professionals began diagnosing depression based on symptoms—such as depressed mood, loss of appetite, and fatigue—that lasted for at least two weeks. This system is fundamentally flawed, the authors maintain, because it fails to take into account the context in which the symptoms occur. They stress the importance of distinguishing between abnormal reactions due to internal dysfunction and normal sadness brought on by external circumstances. Under the current DSM classification system, however, this distinction is impossible to make, so the expected emotional distress caused by upsetting events—for example, the loss of a job or the end of a relationship—could lead to a mistaken diagnosis of depressive disorder. Indeed, it is this very mistake that lies at the root of the presumed epidemic of major depression in our midst.
In The Loss of Sadness, Allan V. Horwitz and Jerome C. Wakefield argue that, while depressive disorder certainly exists and can be a devastating condition warranting medical attention, the apparent epidemic in fact reflects the way the psychiatric profession has understood and reclassified normal human sadness as largely an abnormal experience. With the 1980 publication of the landmark third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), mental health professionals began diagnosing depression based on symptoms—such as depressed mood, loss of appetite, and fatigue—that lasted for at least two weeks. This system is fundamentally flawed, the authors maintain, because it fails to take into account the context in which the symptoms occur. They stress the importance of distinguishing between abnormal reactions due to internal dysfunction and normal sadness brought on by external circumstances. Under the current DSM classification system, however, this distinction is impossible to make, so the expected emotional distress caused by upsetting events—for example, the loss of a job or the end of a relationship—could lead to a mistaken diagnosis of depressive disorder. Indeed, it is this very mistake that lies at the root of the presumed epidemic of major depression in our midst.
312 pages, Hardcover
First published January 1, 2007
36 people are currently reading
1466 people want to read
Ratings & Reviews
Friends & Following
Create a free account to discover what your friends think of this book!
Community Reviews
Displaying 1 - 16 of 16 reviews
January 30, 2014
Fairly shitty.
It took two celebrated scholars to write a book in which a single slim idea is repeated with no variation and virtually no additional information over 225 pages. Okay, so sadness can be confused with major depressive disorder. Okay, I get it.
It took two celebrated scholars to write a book in which a single slim idea is repeated with no variation and virtually no additional information over 225 pages. Okay, so sadness can be confused with major depressive disorder. Okay, I get it.
August 5, 2010
Liked it, but then it agreed with many of my own opinion of psychiatry. I think the idea of normal sadness is something we need to deal better with in the mental health field.
March 21, 2022
oh allan and jerome you so angery but you say the same thing 1200 times
This entire review has been hidden because of spoilers.
June 27, 2012
If you read books on psychiatry this one is excellent (though at times it is academic & clinical), as it discusses subject matter that has been hotly debated for the last two decades regarding what the disorder called depression really is, and if it needs to be treated so extremely with antidepressant medications, long-term therapy, etc.
This book is written by two very thoughtful professionals in the field who do not want to see every human thought, feeling and emotion turn into an over-treated disease, disorder or condition, and then medicated. Some mood swings (maybe many) and emotional adjustments are simply normal reactions to life.
So why are so many people in this country seemingly suffering from depression and why are anti-depressants one of the biggest selling drugs? The answer is that the definition of depression has been set in such a way that many more people than should will be diagnosed as suffering from depression. Many then, and are, being medicated who are not really suffering from depression but are simply responding to a life circumstance, like the loss of a job or the breakup of a romantic relationship. The problem is that reaction to these life events will express the same symptoms as those delineated in the latest version of the mental health diagnostic manual, the DSM, which has broaden what depression. In the end according to this manual at least 25% of all people living in this country are depressed. And in some circles they all should be medicated, at least if we loved them they would be.
In the end we must remember that sadness is an inherent part of the human condition, not a mental disorder. The desire to banish all bad feelings from life reveals a disturbing; one might even say a less than human view of life, philosophy as to the way life should be lived.
This book is written by two very thoughtful professionals in the field who do not want to see every human thought, feeling and emotion turn into an over-treated disease, disorder or condition, and then medicated. Some mood swings (maybe many) and emotional adjustments are simply normal reactions to life.
So why are so many people in this country seemingly suffering from depression and why are anti-depressants one of the biggest selling drugs? The answer is that the definition of depression has been set in such a way that many more people than should will be diagnosed as suffering from depression. Many then, and are, being medicated who are not really suffering from depression but are simply responding to a life circumstance, like the loss of a job or the breakup of a romantic relationship. The problem is that reaction to these life events will express the same symptoms as those delineated in the latest version of the mental health diagnostic manual, the DSM, which has broaden what depression. In the end according to this manual at least 25% of all people living in this country are depressed. And in some circles they all should be medicated, at least if we loved them they would be.
In the end we must remember that sadness is an inherent part of the human condition, not a mental disorder. The desire to banish all bad feelings from life reveals a disturbing; one might even say a less than human view of life, philosophy as to the way life should be lived.
June 9, 2008
A well-argued refutation of the validity of broadening of the definition of depression to include normal sadness, as has happened with using strictly symptomatic diagnositic criteria. The authors propose a return to the criteria used since antiquity through most of the 20th century, that include context, so that depression is sadness "without cause" or "without proportional cause." Now only bereavement is listed as an exceptional circumstance, while divorce, end of romatic relationships, loss of a valued job, being trapped in an ongoing negative situation, etc., are also common causes of normal sadness that has the same symptoms as major depression, but are transitory and not evidence of any mental disease. That the book has a foreword by Robert Spitzer, father of the DSM, even though the authors' position opposes that in the DSM, says to me that this is a consideration of the issue by top scholarly players.
January 19, 2022
The thesis of the book is clear: sadness, regular sadness, is a common human feeling after certain events (bereavement, breakup, loss of a job...) and should not be confused with a medical condition such as depression and, therefore, should not be medicalized and treated as if it were pathological. The authors affirm that DSM-III implied a major shift in the psychiatric treatment of sadness because its diagnose was based only on the presence of certain symptoms (loss of appetite, lack of sleep...) and did not take into account the cause of the feeling, which implied that many "normal" cases of sadness started to be treated as depressions or major depressions; this seems to have changed in DSM-V, which means that their message was received by the medical profession. In any case, the case is powerful, but there is a certain repetition in the argument which makes the book somehow tiresome. Besides, it is based on clinical practice in the US and does not explain how the DSM-III has been applied in other countries. My suspicion is that their argument does not apply to the rest of the world, where people do not usually get medicated in cases of extreme sadness and where psychiatrists are more nuanced in their diagnoses. The health system being what it is in the US (mostly private and profit-driven), it seems that it was not only the DSM-III criteria the culprit but the conditions in which doctors work what made possible the medicalization of sadness.
June 22, 2015
I read the first chapter and part of Chapter 2. I agree with the basic premise that contemporary psychiatry is wrongfully overdiagnosing sadness as a disorder. However, the writing is repetitive, dry, and often abstract, despite well-done references. There are unnecessary literary quotes, like of Mary Shelley. The authors also make assertions that might appear logical, but actually lack good reasoning. I especially dislike their assertions about what human behaviors are 'designed by natural selection,' which are unfounded and as faith-based as religious beliefs. (And I have a science degree, so I'm not against science.)
As someone in Mad Pride and antipsychiatry, the basic premise is an important one, but it's been done before and I think the authors' arguments would have been better as an essay than a book-length manuscript.
As someone in Mad Pride and antipsychiatry, the basic premise is an important one, but it's been done before and I think the authors' arguments would have been better as an essay than a book-length manuscript.
June 26, 2014
The book makes a compelling case for how the practice of psychiatry has conflated sadness with major depressive disorders (MDD). The book goes into more detail than many readers will feel is necessary, but it is certainly worth a look.
Read
July 25, 2011It's smart, insightful and balanced. Unfortunately, it also keeps putting me to sleep.
December 26, 2025
For as long as what we now call depression has been recognised, the distinction between normal sadness with cause, and depression without cause has been recognised, that is until recently. The book is a detailed examination of the erosion of this distinction, its causes and its implications.
Observing an increased incidence of depression in medicine, journal papers and books, the question of whether this increase is actual or due to changes to diagnostic criteria is a primary motif of the book. It summarised the development of classifications of mental illnesses with the first Diagnostic and Statistical Manual (DSM-I) being released in 1952. Twenty years later, John Feighner developed the criteria which bear his name but these criteria were for research, not diagnosis, hence they did not address sadness as a cause of depression. This was followed by the Research Diagnostic Criteria (RDC) which was developed to standardise diagnostics and again included no exclusions for bereavement and in which disorders were described more in terms of symptoms not how they related to one or another psychological school or theory. The book also cited the Rosenham study in which eight persons posing as patients who only heard voices, and all of whom were diagnosed as psychotic and most as schizophrenic, as evidence of the mental health profession’s propensity to overdiagnose.
Significantly, when the DSM-III was released in 1980, it cited the Feighner criteria but no papers reporting empirical research to support their use. It enabled diagnoses to be consistent across different practitioners, even if inaccurate, and it abandoned the distinction between excessive and proportionate responses to an identifiable event, although the distinction was retained for anxiety and related ailments. The exception for bereavement when diagnosing depression was retained. The authors contend that the concern about false negative diagnoses is countered by the potential for false positive diagnoses which also have risks, and costs.
The book then cited studies of soldiers in WWII which also failed to distinguish normal responses to trauma to long term mental illness. It also described the application of Freud’s continuum of community mental health lead to the "conclusion" that almost everyone is potentially at risk, noting studies of the population at large required non-psychiatrists to administer the tests and thus misused context, over diagnosing mental illness in the general population. In a study of mental health in one Nova Scotia county, 57% of those tested were "diagnosed" to have depression.
From the Feighner criteria came the diagnostic interview schedule (DIS) used by researchers, not psychologists, to test the general population to determine the unmet mental health needs in the community, however the lack of discretion and permission to ask clarification questions led to ridiculously high claimed rates of depression which, in turn, led to demands for massive increase in resources to treat this supposed need. The book explained the processes of screening & pre-screening and its use of the methods for physical health, but that mental health pre-screening emphasised missing no one with a mental disorder, hence there were many false positives.
The book also examined the not always recognised distinction between normality and disease, citing gum disease which is normal but still a disease whereas some personality traits are unusual but not a disorder, a dysfunction that is harmful, in the medical sense. It also cited shortcomings of classifying symptoms of depression as being on a continuum and the assumption that any symptom may lead to full depression, comparable to claiming that one cough just might indicate tuberculosis, which led to over diagnosis, noting that the vast majority of those with minor symptoms do not develop major depression. This led to providing mental health services to many in the 1960s with problems of living and less to those with actual mental illnesses. Mass screenings of children in schools in an attempt to find indicators of suicide potential found high rates of mental illness and, once again, normal sadness with cause was not considered.
This was followed by observation that after the USA’s Food and Drug Administration (FDA) allowed direct to consumer ads (DTC) for medications in 1997, there was a significant growth in prescriptions for anti-depression meds thereafter in part because patients got prescriptions from GPs, not psychiatrists. It also noted that the fields anthropology, which could have countered the non-distinction between sadness and depression but instead copied it, and sociology, whose Center for Epidemiological Studies measure of depression (CES-D) was even more likely to classify episodes of normal sadness as depression than the DSM, failed to provide a counter the increasingly entrenched non-distinction between normal sadness with cause, and depression. The last chapter summarised and cited why the resistance to change, one reason being that a significant body of research, albeit all based on an invalid definition of depression, would become obsolete. But the financial implications for the entire medical industry that currently treats genuine depression as well as normal sadness seen as depression if the diagnostic criteria were to recognise that sadness with cause is not the same as depression, cannot be ignored.
The book was nothing if not thorough and comprehensive in its examination of the medical profession’s non-recognition of sadness with cause. However, writing this book in a style appropriate to a wider audience but packed to overflowing with detailed and, at times, repetitive citations more aimed at a specialised audience within the field of government health care policy was a bit much for this member of that wider audience. For me, an article that summarised its findings in a serious lay journal such as Quadrant or The New Yorker would have been more appropriate.
Observing an increased incidence of depression in medicine, journal papers and books, the question of whether this increase is actual or due to changes to diagnostic criteria is a primary motif of the book. It summarised the development of classifications of mental illnesses with the first Diagnostic and Statistical Manual (DSM-I) being released in 1952. Twenty years later, John Feighner developed the criteria which bear his name but these criteria were for research, not diagnosis, hence they did not address sadness as a cause of depression. This was followed by the Research Diagnostic Criteria (RDC) which was developed to standardise diagnostics and again included no exclusions for bereavement and in which disorders were described more in terms of symptoms not how they related to one or another psychological school or theory. The book also cited the Rosenham study in which eight persons posing as patients who only heard voices, and all of whom were diagnosed as psychotic and most as schizophrenic, as evidence of the mental health profession’s propensity to overdiagnose.
Significantly, when the DSM-III was released in 1980, it cited the Feighner criteria but no papers reporting empirical research to support their use. It enabled diagnoses to be consistent across different practitioners, even if inaccurate, and it abandoned the distinction between excessive and proportionate responses to an identifiable event, although the distinction was retained for anxiety and related ailments. The exception for bereavement when diagnosing depression was retained. The authors contend that the concern about false negative diagnoses is countered by the potential for false positive diagnoses which also have risks, and costs.
The book then cited studies of soldiers in WWII which also failed to distinguish normal responses to trauma to long term mental illness. It also described the application of Freud’s continuum of community mental health lead to the "conclusion" that almost everyone is potentially at risk, noting studies of the population at large required non-psychiatrists to administer the tests and thus misused context, over diagnosing mental illness in the general population. In a study of mental health in one Nova Scotia county, 57% of those tested were "diagnosed" to have depression.
From the Feighner criteria came the diagnostic interview schedule (DIS) used by researchers, not psychologists, to test the general population to determine the unmet mental health needs in the community, however the lack of discretion and permission to ask clarification questions led to ridiculously high claimed rates of depression which, in turn, led to demands for massive increase in resources to treat this supposed need. The book explained the processes of screening & pre-screening and its use of the methods for physical health, but that mental health pre-screening emphasised missing no one with a mental disorder, hence there were many false positives.
The book also examined the not always recognised distinction between normality and disease, citing gum disease which is normal but still a disease whereas some personality traits are unusual but not a disorder, a dysfunction that is harmful, in the medical sense. It also cited shortcomings of classifying symptoms of depression as being on a continuum and the assumption that any symptom may lead to full depression, comparable to claiming that one cough just might indicate tuberculosis, which led to over diagnosis, noting that the vast majority of those with minor symptoms do not develop major depression. This led to providing mental health services to many in the 1960s with problems of living and less to those with actual mental illnesses. Mass screenings of children in schools in an attempt to find indicators of suicide potential found high rates of mental illness and, once again, normal sadness with cause was not considered.
This was followed by observation that after the USA’s Food and Drug Administration (FDA) allowed direct to consumer ads (DTC) for medications in 1997, there was a significant growth in prescriptions for anti-depression meds thereafter in part because patients got prescriptions from GPs, not psychiatrists. It also noted that the fields anthropology, which could have countered the non-distinction between sadness and depression but instead copied it, and sociology, whose Center for Epidemiological Studies measure of depression (CES-D) was even more likely to classify episodes of normal sadness as depression than the DSM, failed to provide a counter the increasingly entrenched non-distinction between normal sadness with cause, and depression. The last chapter summarised and cited why the resistance to change, one reason being that a significant body of research, albeit all based on an invalid definition of depression, would become obsolete. But the financial implications for the entire medical industry that currently treats genuine depression as well as normal sadness seen as depression if the diagnostic criteria were to recognise that sadness with cause is not the same as depression, cannot be ignored.
The book was nothing if not thorough and comprehensive in its examination of the medical profession’s non-recognition of sadness with cause. However, writing this book in a style appropriate to a wider audience but packed to overflowing with detailed and, at times, repetitive citations more aimed at a specialised audience within the field of government health care policy was a bit much for this member of that wider audience. For me, an article that summarised its findings in a serious lay journal such as Quadrant or The New Yorker would have been more appropriate.
April 3, 2021
The authors bring up an interesting point about the modern medicalization of depression. They raise concerns about the importance of considering an individual’s circumstances that precede clinical depression.
The authors use evolutionary arguments to suggest how sadness in response to loss may have been a selected, beneficial trait. They urge that better understanding of depression that arises from loss will have profound treatment and research implications.
Examples and elaborations are included to make understanding the arguments much easier, and to ground them into reality from abstract concepts.
The authors use evolutionary arguments to suggest how sadness in response to loss may have been a selected, beneficial trait. They urge that better understanding of depression that arises from loss will have profound treatment and research implications.
Examples and elaborations are included to make understanding the arguments much easier, and to ground them into reality from abstract concepts.
This entire review has been hidden because of spoilers.
August 24, 2021
Should you really trust your psychiatry's diagnosis when he said after comparing your symptoms with the DSM-V checklist, your normal sorrow is Major Depressive Disorder? Not so fast. Reading this book to have a better understanding of the depression industry.
October 3, 2017
3.5 stars.
Read
December 1, 2022Is this a textbook? Good grief. It sounds fascinating but I can't seem to absorb any of the information. Guess I'm not the target audience
September 23, 2012
Intriguing! Well worth the read so far.
Displaying 1 - 16 of 16 reviews