David Geaney, Consultant Psychiatrist and Honorary Senior Clinical Lecturer
18 January 2012

In his response to my letter, Mario Maj appears to argue that when sadness or depression deserve clinical attention, they should automatically be considered a disorder (1). Yet this approach is obviouslyinvalid when extended to other branches of medicine, as illustrated by thecare of women, including analgesic use, during childbirth, when this is clearly not a disordered state. Similarly, while it may be appropriate, for example, to give antidepressant treatment to an individual with markedly low mood in the context of a terminal illness, that does not meanthat a disorder is being treated.

Even the draft definition of a mental disorder in DSM-5 (www.dsm5.org), based upon the proposals of Stein et al (2), includes the criterion that it 'must not be merely an expectable response to common stressors and losses' and Stein et al acknowledge that 'although it may bedifficult to define the term "expectable", it is important to retain an emphasis on exploring the context of symptoms'. Of course there is no sharp divide between what is or what is not expectable and a value judgment is required. However, this is consistent with the position adopted in the DSM-5 draft discussion which states that 'no definition perfectly specifies precise boundaries for the concept of either "medical disorder" or "mental/psychiatric disorder"'.

Mario Maj is concerned that subjective criteria for deciding whether a given depressive response is proportionate or not to a given life event,might lead to some mental health professionals concluding that all psychopathology is attributable to the environment, but this does not justify polarising to the opposite view and concluding that significant sadness should never be attributable primarily to the environment and should always be considered a disorder. There is surely a more reasonable middle ground to be advocated. While Kendler has reservations, even he acknowledges that there is 'a deep issue in our field that will not easilygo away' and that subjective 'criteria could be operationalised and thereby made more objective' (3). An alternative approach might be to significantly raise the threshold for the diagnosis of depressive disorder.

In advocating his pragmatic approach, Mario Maj completely overlooks the consequences of abandoning the concept of disorder in favour of that of a problem deserving clinical attention. Encouraging patients to consider any significant sadness as a disorder that has afflicted them, somewhat like an infection, can promote a lack of resilience within society by reducing tolerance of normal unpleasant emotions, impairing theunderstanding that it is normal for stress to produce negative emotions, and diminishing the sense of autonomy in resolving the real difficulties in life which may have contributed to the episode of low mood. Anecdotally, colleagues and I are now seeing intelligent young people who present with minor psychological symptoms and who do not appear to connectthese at all with the circumstances of their life, but instead offer a self-made diagnosis from current diagnostic criteria, seeing themselves asrelatively passive victims of a disorder.

An evolutionary approach can encourage us to consider what broader factors in society may be contributing to the current high prevalence of psychological symptoms. A mismatch between our brains, which evolved in our hunter-gatherer past, and our current environment, suggests potential candidates. These include the lack of support, from small, egalitarian, cohesive groups, in a society with limited social connectedness or social capital and marked inequality, whose effects are exacerbated by the media encouraging the pursuit of unreachable goals (4). A recent meta-analysis has estimated that a lack of social relationships has an effect upon an individual's physical health which is similar in magnitude to that of smoking (5). Surely we should also be considering more actively what environmental factors are harming our mental health and encouraging the public to consider what action should be taken as a consequence.

1.Maj M. Depression: a cultural panic attack. Br J Psychiatry 2011 199:513; doi:10.1192/bjp.199.6.5132.Stein DJ, Phillips KA, Bolton D, Fulford KWM, Sadler JZ, Kendler KS. What is a mental/psychiatric disorder? From DSM-IV to DSM-V. Psychol Med 2010; 40:1759-653.Kendler KS. Book review: The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Psychol Med 2008; 38:148-504.Wilkinson R, Pickett K. The Spirit Level: Why more equal societies almost always do better. Allen Lane, 20095.Holt-Lunstad J, Smith TB, Layton JB. Social Relationships and MortalityRisk: A Meta-analytic Review. PLoS Med 7(7):e1000316.doi:10.1371/ journal.pmed.1000316

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Conflict of interest: None declared