The book provides a deep critique of the way DSM has been doing business. Let me try to succinctly capture the heart of the issue. If an individual experienced a full-blown panic attack when, as a lead climber toward the top of a 1500-foot cliff, he looses his grip and falls 40 feet before his rope catches him and he hangs dangling looking a long way down the mountain side, no psychiatrist I know would consider this to be a psychopathological phenomenon. A panic attack is not – in and of itself – psychopathological. It only becomes pathology when it occurs in certain contexts – at times and in places when it should not. Thus the diagnostic status of panic disorder is inherently contextual. It is not a disorder in and of itself but only in certain contexts. That is, the diagnosis of panic disorder is not simply a thing out there in the world that we describe and classify. It is a thing plus the value judgment that it is ‘unexpected.’

Now, let us take a bizarre delusion – ‘A hard drive has been installed in my brain by aliens because they want to send me in a space pod to Alpha Centuri to contact the advanced civilizations there.’ Does it matter in our consideration of this symptom whether the patient has just split up from his long-term girlfriend, was sexually abused as a child or has recently lost his job? Putting aside the rare cases where such symptoms might be explicable from neurological lesions or drugs of abuse, this symptom is inherently pathological. It does not need to be interpreted in its psychosocial context to decide whether this represents a ‘normal’ response to some adversity.

So, to a first approximation, panic attacks are inherently contextual and bizarre delusions are ‘in and of themselves’ pathological. The question posed by the book of Horwitz and Wakefield (H&W) is: where does major depression (MD) sit in this continuum? Is a full depressive syndrome inherently pathological in nature or is it only pathological when it occurs in certain contexts? This book is, in essence, one long argument for the latter position.

On what do they base this claim? Of their wide ranging arguments, I will review five. First, they suggest that common sense indicates that there is a critical distinction between ‘normal sadness’ and MD. As they illustrate from a range of literary examples from Gilgamesh to Anna Karenina, humans have evolved to become sad and depressed after bad things happen to them. This is, they argue, evident because of the cross-cultural and historical uniformity of the normal sadness. They write

We should not, they argue, be making disorders out of such syndromes.

Second, they quote extensively from a wide range of historical authors from Hippocrates and Aristotle on one end to Krafft-Ebing and Kraepelin on the other all making the point that depression should be considered a disease only if the reaction is out of keeping with the severity of the precipitant. Two examples will suffice. The first is from Greisinger (1817–1868):

And the second from Charles Mercier (1852–1918) who succinctly defined melancholia as ‘a disorder characterized by a feeling of misery which is in excess of what is justified by the circumstances in which the individual is placed’ (p. 69).

Third, H&W point out that DSM could not itself make up its mind about this question. DSM-III and all subsequent DSM editions have contained the grief exclusion. That is, they list one psychosocial context in which MD (like the panic attack during the climbing accident) should not be considered psychopathological. They ask, with some force, why should only bereavement and not the wide array of possible adversities be so treated? They review data subsequently published by the authors (Wakefield et al. Reference Wakefield, Schmitz, First and Horwitz2007) that empirically supports their claim that episodes of ‘uncomplicated depression triggered by bereavement’ are clinically quite similar to depressions that are triggered by other kinds of loss events. Not surprisingly, they suggest that the solution to the inconsistency in the DSM is to extend the ‘grief’ exclusion to all depressive episodes related to psychosocial adversity.

Fourth, the authors use an old argument often advocated by the anti-psychiatry movement. They write ‘One argument against medicating normal sadness is that it treats as pathological what is actually an inherent and valuable part of the human condition.’ In my opinion, this approach runs the risk of over-romanticizing the suffering associated with MD. I have no better response to this concern than a clinical vignette from the 1970s, early in my training.

Although I found her depression to be entirely appropriate to her tragic situation, the argument that I should not have treated her so that she could experience an ‘inherent and valuable part of the human condition’ obviously rings rather hollow.

Fifth, in a quiet and sober (rather than rabid) manner, H&W raise the specters of self- interest in the elaboration and propagation of these criteria first proposed in the Feighner criteria (Feighner et al. Reference Feighner, Robins, Guze, Woodruff, Winokur and Munoz1972) and then adopted into the Research Diagnostic Criteria (Spitzer et al. Reference Spitzer, Endicott and Robins1975) and them DSM system (APA, 1980). Clearly, they argue, drug companies and the psychiatric profession benefit from what they consider to be this new and overly wide definition of MD. Given the number of patient visits or prescriptions filled for MD, how, they ask, can we expect the psychiatric profession to appropriately police themselves and reverse what they see as this fundamental conceptual error – of making the diagnosis of MD context-less?

How do these and related arguments sit with this reviewer who, in the spirit of complete disclosure, was taught and has used throughout his career, a ‘context-independent’ construct for MD? Undoubtedly, some of H&W's arguments have force. However, this book has one major weakness that makes a careful reading of it frustrating if not infuriating. Although the phrase ‘normal sadness’ constantly appears in this book, mantra-like, the authors never present a convincing method whereby it would be possible to distinguish between ‘normal sadness’ and MD. They do briefly review Wakefield's famous ‘harmful dysfunction’ model for psychiatric disorders but that does not help the problem much as we are left with having to define when MD represents a dysfunction.

To their credit, H&W admit that some of the standard approaches that might spring to mind to help discriminate normal sadness and MD are not likely to work. That is, they note that normal sadness can be associated with changes in brain function and psychosocial impairment. They review evidence that normal sadness can respond to psychological or pharmacological treatment. At several points in this book, I felt like a young Karl Popper reviewing Marxist and Freudian theory trying in vain to find something I could try to disprove. I kept wanting them to give me an experiment I could conduct that would crisply and empirically evaluate their central hypothesis – that normal sadness differs from MD. I never could find one. Indeed, at times, the authors make clear that they regard the truth of their position to be an a priori one. For example, they write

The authors also fail to position their concerns in the context of the long-running debate about the role of values versus facts in psychiatric diagnosis. That is, can diagnosis in psychiatry be a purely factual or scientific exercise or must it inevitably involve value judgments – such as whether a particular set of symptoms of panic, depression or fear in a particular biographical context – is ‘normal’?

I was left with the uneasy feeling that, at bedrock, the distinction between normal sadness and MD will have to be made by what at basis will be the subjective criteria proposed by Jaspers in his old idea of ‘understandability’. Undoubtedly, such criteria could be operationalized and thereby made more objective. Despite my sympathies with some of the positions of the authors, I could not help but feel that this was more a step backward than forward for our field. But, in their defense, how different is this from our all agreeing that the climber dangling from the rope has a clearly ‘understandable’ and hence non-pathological panic attack? So I recommend this book for those who want to poke about in the conceptual foundations of our diagnostic systems. While flawed in some rather important ways, it is useful and challenging particularly because it boldly highlights a ‘deep’ issue in our field that will not easily go away.

To balance the forceful collection of historical quotes in favor of their position that H&W assemble, I conclude this review with a far more skeptical opinion by Aubrey Lewis taken from his famous and very detailed study of 61 cases of depressive illness (Lewis, Reference Lewis and Lewis1967). He describes his attempt to apply previously proposed criteria to separate his patient group into those whose illness could easily be understood as contextual (or ‘psychogenic’) versus endogenous: