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However we choose to define depression, both its frequency and its disruption of normal life are staggering. The World Health Organization named depression the second most common cause of disability worldwide after cardiovascular disease, and it is expected to become number one in the next ten years. In the United States, 5 to 10 percent of adults currently experience the symptoms of major depression (as previously defined), and up to 25 percent meet the diagnostic criteria during their lifetime, making it one of the most common conditions treated by primary care physicians. At any given time, around 15 percent of American adults are taking antidepressant medications.

Studies of religious groups, from Orthodox Jews to evangelical Christians, reveal no evidence that the frequency of depression varies across religious groups or between those who attend religious services and those who do not. So in a typical congregation of 200 adults, 50 attendees will experience depression at some point, and at least 30 are currently taking antidepressants.

How do we explain these numbers? In part, they result from a two-pronged shift in cultural attitudes about depression. Groups such as the National Alliance on Mental Illness and pharmaceutical companies have aggressively promoted the view that depression is not a character flaw but a biological problem (a disease) in need of a biological solution (a drug). The efforts to medicalize depression have helped to remove the stigma attached to it and convince the public that it's not something to hide. Consequently, depression has come out of the closet.

Some critics argue that along with the disease view of depression comes a lowered diagnostic threshold. Professors Allan Horwitz and Jerome Wakefield argue in The Loss of Sadness (Oxford, 2007) that psychiatrists no longer provide room for their clients' sadness or life's usual ups and downs, labeling even normal mood fluctuations "depression." (Everyday conversation reflects this assumption. When asked how we are doing, we commonly answer "great" or at least "good." If we reveal that we're "fine"—or worse, just "okay"—people tend to assume something is wrong and begin probing.)

Critics like Horwitz and Wakefield are half right. It is true that the mental health community has lowered the threshold for recognizing depression. Yet when we trace depression in the United States over the past 20 years using fixed criteria—the very research I do—we still see a significant increase in frequency. So although the numbers may be inflated, and this bump unquestionably serves the profit margins of pharmaceutical companies, we nevertheless have a substantial, documented increase to try to explain.

Our society has reaped considerable benefit from casting a wide net and assuming that everything caught is a disease. We now are more attuned to depression's burden of emotional suffering, better understand biological factors, and have medications that address those factors. We should be thankful for these significant gains.

Yet redefining depression broadly as a disease has some untoward consequences. This model rightly acknowledges the biological aspect of human nature and how it can become disordered. But it fails to consider other dimensions at play. For example, the disease model ignores social environments as possible contributors to depression, viewing depressed persons as isolated individuals with a strong boundary between their bodies and everything outside. Depressed persons are reduced to broken bodies and brains that need fixing.

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March 2009, Vol. 53, No. 3