Separation of anxiety and depressive disorders

Editor—Shorter and Tyrer provide an important case study in the way that medicine and science can become subverted by commercial pressures.¹ On one hand, new patents for drugs for mood and anxiety disorders have dwindled to almost nothing from a high point in the 1960s and 1970s. On the other, niche diagnoses have proliferated, apparently as a result of collusion between experts and the pharmaceutical industry. In the absence of new drugs for existing conditions, it seems, a good commercial alternative is to market the existing drugs as being effective for new diagnoses.

However, if we accept the existence of this association, the direction of causation is unclear. The authors believe that the failure to advance the treatment of anxiety and depression is related to the wrong classification—with the implication that use of a superior categorisation that no longer separates the two diagnoses would stimulate pharmaceutical innovation. But it could equally well be true that the proliferation of niche diagnoses is a commercial strategy that is a response to the absence of good new drug discoveries. After all, other sections of the industry have also experienced a falling off of new patents—for example, antibiotics.

Perhaps we will not have any new therapeutic agents for anxiety or depression, as we may have reached the limits of this pharmacological approach. The fact that these two symptoms tend to occur together in real life should not obscure that they are just that: symptoms, not diagnoses. A diagnosis provides an explanation of symptoms (and other manifestations of a disease process) that goes beyond their mere description, even if that does include a dimensional approach to defining illness. It is unclear that there is a diagnosis to find here, beyond the attempt to understand why some people—and some cultures—tend to respond in this way to adverse life situations.