It is questionable whether psychiatry as a whole does, or has done throughout its history, more good than harm. Certainly there are some patients who benefit from its ministrations; but there are many others who have been harmed by the wrongful administration of noxious drugs or other therapies. A less tangible, but nevertheless potentially serious, harm is that it persuades people with the difficulties in living that are inseparable from human existence that they are ill, and therefore disguises from them that the best remedy, if one there be, lies in their own hands. Indeed, psychiatry seems to have persuaded whole societies that all forms of mental distress are illnesses, for which there is a technical medical solution.
I confess to having approached Lisa Appignianesi’s book with something like dread. I thought it would be a simple-minded catalogue of wrongs committed by male psychiatrists against women, but I was quite wrong. The author recognises the inherent ambiguities and difficulties of the field, which speaks to her honesty; she weaves a seamless robe from individual case histories (often of murderesses or suicides), literature and the theoretical writings of psychiatrists. She has a good measure of what in fact is not very common, namely common sense, and this lends an exemplary clarity to her prose. Her range of reference is very large, and although her book concentrates on the treatment of women, it does so in no sectarian spirit, and can be recommended to anyone interested in the history of psychiatry. Indeed, I would say that it is the most readable and elegant history of the last two centuries of psychiatry that I have read.
The Loss of Sadness is one of the most important books in the field of psychiatry published in the last few years. The authors are two American professors of sociology, but (I almost said nevertheless) they present a powerful argument that is so good that they do not have to obscure it with convoluted prose.
They attack head-on the Diagnostic and Statistical Manual of the American Psychiatric Association, particularly its definition of depression. The DSM IV, as it is everywhere known, has been treated around the world with a superstitious veneration that makes that accorded to miracle- working virgins appear moderate and rational. It is nonetheless an intellectual house of cards.
For a doctor, or indeed anyone else, to diagnose someone as suffering from major depression, all that he need do is check that a person has suffered from five out of nine symptoms, all of them very common, for at least two weeks. The context in which he suffers them is quite irrelevant.
This means that the diagnosis can be made reliably — anyone, after all, can tick the requisite boxes and count up to five. But the question of whether the diagnosis is valid, that is to say that it refers to or picks out anything that actually exists in nature, is extremely doubtful. Indeed, common sense and reflection on the most elementary knowledge of human life suggests that it does not.
As the authors point out with great clarity, this is not a matter of merely theoretical interest. The adoption of the DSM IV definition of depression has had several baleful consequences. There is no scientific reason why depression should be diagnosed in the presence of five rather than four or three symptoms, and indeed a movement has grown up to recognise lesser degrees of supposed depression which, if treated, will avoid the development of more serious depression. Thus the number of supposedly depressed people keeps expanding like the ripples on a pond after a stone has been thrown into it. DSM IV has encouraged the development of intrusive and even sinister screening instruments to detect so-called depression in large populations (the American government wants every adolescent in the country screened for depression). It has encouraged the widespread and grotesque overprescription of anti-depressants, whose side-effects are real but whose benefits are doubtful. It encourages people to disavow responsibility for their own lives and to think of and present themselves as ill. It dehumanises medicine and psychiatry, by discouraging interest in the lives of patients other than as bearers of symptoms. It is scientistic rather than scientific, and has promoted immense quantities of junk science.
In short, in many respects DSM IV represents a regression of knowledge rather than an accretion of it. This does not mean that it will be replaced soon by something better, for powerful vested interests have now developed to prevent it. Although the pharmaceutical companies did not influence the development of DSM IV, it has been an immense boon to them, for under its auspices almost all human behaviour becomes a medical condition potentially treatable with medications; lawyers love it because it makes so many events actionable under tort law; governments love it because unhappiness becomes an illness rather than a natural consequence of social arrangements; and patients love it because it absolves them of the painful responsibilities of their own humanity.
In short, this is a brilliant book with a significance well beyond its narrow but important subject. It will be ignored.
This article first appeared in the print edition of The Spectator magazine, dated March 15, 2008