Dr. Vale (1) suggests that the current definition of major depressive disorder is too heterogeneous and that there are many distinct depressive subtypes that manifest differently but that share a similar physiological profile. He argues that biological markers should be included in studies of disease-related psychosocial stress. We agree in principle that there are a variety of syndromes that include negative affect as a major component and that clinical depression presents in a variety of forms. We raise two issues with respect to Dr. Vale's thoughtful comments.
First, although we reported in our study that the prevalence of clinical depression, defined as major depressive disorder, was ∼50% higher among patients with diabetes than among community dwellers (2), we also reported that many more patients were not clinically depressed, but were, instead, distressed and worried about their diabetes and its management. Although a patient's level of disease-related distress is of considerable concern, we and others (3) have cautioned against the common practice of considering distress and stress as conditions characterized as psychopathology. Even though most chronic stress has physiological ramifications, as do some forms of common pleasure, we argue against both the increasing “medicalization” of sometimes painful but understandable affective states and the tendency toward biological reductionism regarding explanations and interventions (4,5). Although we fully support the study of the physiology of distress, we distinguish between states that should be considered psychopathological and conditions that are part of the broad spectrum of human experience. A major problem with this modern tendency toward medicalization is that it narrows our understanding of the processes involved, and it tends to shift interventions away from the personal, social, and environmental determinants of distress to often expensive and sometimes unnecessary medical interventions (5). Thus, patients return for medications or are referred for narrowly defined treatment for conditions that are really part and parcel of living with and coping with a chronic disease. This tendency, in our view, disempowers patients, enhances their dependency, increases health care costs, and reduces intervention options.
Second, our argument against medicalization of diabetes-related distress does not imply a lack of concern about the impact of distress on quality of life and on diabetes-related markers. Our report is but one of many that attests to the importance of recognizing distress as part of good diabetes care (6). We are dismayed by the absence of any indicator of distress, quality of life, clinical depression, or any patient-centered measure in current versions of HEDIS (Health Plan Employer Data and Information Set) or the National Committee for Quality Assurance, while at the same time targets for biological markers are becoming more stringent and are applied without reference to patient goals, comorbid conditions, or other factors (7,8). The literature has clearly documented the importance of both clinical depression and distress on disease outcomes, and it is time that measures of quality of care include these dimensions to provide a comprehensive picture of patient status, as recommended by the Institute of Medicine (9) and widely used in other countries (10).
