Depression: beyond the disease era

Depression has now become established as one of the major illnesses affecting the mind. It is heading for even greater heights, moving rapidly up the charts of the world's top ten disabling diseases, and tipped to achieve an impressive second place by the year 2020.1 What is going on? Is there an epidemic of misery and sadness sweeping the world, a time bomb of depression waiting to explode?2 Or are we radically altering our interpretation of our perceptions, our physical and emotional experiences, even our understanding of the human condition? While the diagnosis of depression may have a definable utility, I think it is often insufficient, sometimes unnecessary, and occasionally harmful. It encapsulates certain aspects of human experience, and in so doing sets artificial boundaries around them, conferring on them both the rights and responsibilities of an illness, and leading us towards treatment paradigms which tend to reduce – rather than enhance – our ability to live our lives. We use it too readily as a tool to create an artificial sense of order, an ‘irritable reaching after fact and reason’, when we may do better to follow Keats' advice and remain in ‘uncertainties, mysteries, doubts’,3 particularly when the boundaries between emotional and physical problems are unclear, and our attempts to create a distinction are misleading and potentially damaging. As a concept it is severely constrained by language and culture, and may easily be turned to the advantage of vested interests. The time has come to abandon the concept of disease as the focal point of depression care. Instead of making diagnoses and management plans on the basis of structured histories, examination and special investigations, clinical decision making should be predicated on the attainment of patient goals and the identification and treatment of modifiable factors.4 We should talk to our patients about their concerns and priorities, the factors which impede their goals, and the types and outcomes for treatment which they consider to be important.