by Hagop S. Akiskal and Giovanni B. Cassano
The Guilford Press, 1997
Review by Christian Perring, Ph.D. on Jun 21st 1998
Chronic low-level depression is gaining increasing recognition as a serious problem. That is partly because there are now drugs that can help the condition, and a problem is more likely to be acknowledged if there is a solution to it. The condition is now less likely to be seen as a problem of character or neurosis, and is more likely to be seen as "biological." This helps to destigmatize such depression.
There is still controversy about low-level depression, however. Some think that allowing this to count as a mental disorder is part of the medicalization of everyday life, and that we should not expect to be able to be happy all the time. Others are willing to agree that the condition is a mental disorder, but are unhappy about how it is classified: "dysthymia" is now the major category for this condition, and "neurotic depression" has been ditched as a psychiatric classification in both DSM-IV and ICD-10.
Dysthymia and the Spectrum of Chronic Depressions is a collection of papers by psychiatric researchers that address these controversies, stemming from a 1992 conference. Most of the papers are relatively short, at around 10 pages. Three papers are more substantial: Hagop Akiskal's Overview, and two papers arguing for and against the concept of neurotic depression, the first by Martin Roth and C. Q. Mountjoy, and the second by Mario Maj. The other papers address a variety of topics, such as residual major depression, pharmacotherapy, depressive personality, chronic fatigue, atypical depressions and childhood depression. The papers are aimed at other researchers and psychiatrists, and use psychiatric jargon without accompanying explanation. This will make it hard for most lay readers to follow the discussion.
In reading through these papers, it is striking how issues of classification are dependent on more than just experimental studies. Different psychiatric traditions fight over turf, and social issues enter in with little announcement. The debate between "dysthymia" and "neurotic depression" is largely between biological and the psychodynamic approaches. The differences in the diagnostic criteria of these two conditions are not large, and it might be hard to see why people would spend so much time debating which category is more useful. The ideological differences at issue become clearer when one realizes that one of the main reasons that dysthymia took over from neurotic depression in the third edition of the Diagnostic and Statistics Manual (1980) (DSM-III) was that practicing psychiatrists tended not to treat neurotic depression with drugs, while they did treat dysthymia with drugs. The editors of DSM-III felt that the change in usage would avoid the problem of under-treatment of this form of depression. So this is why so much is at stake in an apparently minor alteration of terminology.
It is clear from most of the papers here that while much research has been done to tease out differences between different forms of depression, it is hard to find solid evidence that they are really separate conditions. At best the papers here tend to conclude that the evidence that we have is suggestive, and that more research needs to be done in order to confirm the postulated reliable differences between these disorders in question. If present trends continue, the number of people diagnosed with depression will increase significantly over the coming decades, and we need to ask ourselves what sort of classification of depression will be most useful. The point of psychiatric classification is to establish a common language for clinicians and researchers. But we also need to recognize that the classification of mental disorders has social effects, and we should take account of these too. What is missing from Dysthymia and the Spectrum of Chronic Depressions is any discussion of this aspect of the debate about dysthymia.