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Sadness is normal because life can be difficult.1 2 Sadness in bereavement, for example, is appropriate and healthy—I hope my children will be sad after I've gone. However, sadness is not depression: when it is combined with cognitive, emotional, somative, and behavioural features it becomes the syndrome of depression, with its multifactorial aetiology, so common in primary care. But diagnosis does not mean that treatment or medicalisation is needed. The Diagnostic and Statistical Manual of Mental Disorders (III and IV) divides major depressive disorder into mild, moderate, and severe. The mild form is usually self limiting and responds to cognitive behavioural therapy, support, counselling, St John's wort, reading helpful books, etc. It does not really require a doctor so much as supportive, informed listening people, which risks undermining the serious message when doctors are useful.
At the other end of the spectrum, about a quarter of our depressed patients in east London primary care have severe depression when they present. They are at risk of admission, and about 15% will die from suicide. The syndrome here is so far away from normal function and normal sadness, and medical intervention makes such a difference that it is hard not to conceptualise it as illness. If mild depression is like a cold that we could consider a normal part of life, severe depression is like pneumonia that kills people if we do nothing.
Parker seems to muddle all these forms of depression into one, unhelpfully confusing the issues.1 If we treat all depression outside hospital as if it were the same we will undertreat some very sick people, and include in medical treatment those we might prefer to find their own help in their own social networks. The task of primary care is to grade depression appropriately and match severity to treatment, and, of course, treatment may include chemicals, talking, support, self help, and more.
Competing interests: None declared.