Depression: epidemic or pseudo-epidemic?
Derek Summerfield
Institute of Psychiatry, King's College, London, UK
E-mail: derek.summerfield@slam.nhs.uk
There are a number of under-examined fault lines running through the medical literature on depression, and current clinical practice in the UK. This chiefly stems from a too exclusively biomedical focus, neglecting the social construction of the human mind. For a start, the term `depression' tends to be used without qualification, as if it was settled that we were always referring to a free-standing biologically-based disorder. Yet in everyday usage, as much by doctors as by the general public, `depression' can mean something figurative or literal, can denote a normal or abnormal state, and if abnormal either an individual symptom or a full-blown disorder. And though depression-as-disease may have acquired the status of a natural science category, this was an achievement rather than a discovery: the history of the concept demonstrates the gradual incorporation of a Western cultural vocabulary of guilt, energy, fatigue and stress.1
Orthodox teaching has been that a `functional shift', the presence of so-called biological features, points to medically significant depression (and responsiveness to anti-depressants). But, bar a small subset of severe cases, there is no reliable demarcation of depression from ordinary unhappiness or misery on this basis. Poor sleep and concentration, weight loss, reduced motivation and drive, anhedonia, etc. (as well as suicidal ideas), not uncommonly accompany ordinary misery as well.
In 1996, just before the Royal Colleges of Psychiatrists and General Practitioners began a Defeat Depression campaign, they surveyed lay people's attitudes to depression and its treatment.2 The views they elicited tended to portray depression in terms of emotional problems, like unhappiness, caused primarily by social and situational factors, and not something to take to general practitioners (GPs). Of the 2003 people polled, 78% saw anti-depressants as addictive, and liable to dull symptoms rather than solve the problem. The Royal Colleges seem to have been undeterred by these findings, which were rather at odds with their view of `depression' as straightforwardly connoting a psychiatric disorder. Indeed the Royal Colleges initiated the Defeat Depression campaign because they believed that 50% of people with depression did not consult their GPs. They wanted to increase this figure. But was the lay view wrong? We can see here how professional pronouncements can contribute to a blurring between unpleasant but commonplace mental states, part of life, and those associated with objective dysfunction and breakdown, meriting medical attention.
The other explicitly stated reason for the campaign was the belief that GPs often missed depression anyway. Since then the notion that there were large numbers of undiagnosed cases has been remarkably tenacious. Why? There is, in fact, no sound evidence for an epidemic of depression (as psychiatric disorder) in the UK. On the other hand, the case for an epidemic of antidepressant prescribing is now cast iron. In Britain prescriptions rose from 9 million to 21 million during the 1990s, and in the USA have doubled in only 5 years—mirroring the production and marketing of SSRI (selective serotonin reuptake inhibitors) antidepressants.
What remains striking is how unrobust the evidence base for antidepressants still is, particularly for the mild/moderate cases that account for the majority of all prescriptions.3 Part of the reason is surely that antidepressants will not cure human misery, whether presenting in primary care or in psychiatric clinics. Indeed many of those difficult cases described in psychiatric journals as having `treatment resistant depression' may be `resistant' precisely for this reason.
It is possible that this repeatedly aired assumption about under-recognition at primary care level has itself led GPs to prescribe more readily. Further, some GPs prescribe for low mood per se, even if other features of the syndrome are absent, and the simpler dose regimens of SSRIs by comparison with tricyclics have helped. Patient feedback is influenced by placebo effects, and by factors like nonspecific sedation that have nothing to do with `antidepression'. People whose record indicates prior prescription of anti-depressants are more likely to be prescribed them again at a later time by other doctors. It remains to be seen if NICE guidelines—which do not recommend antidepressants as the primary intervention in `mild/moderate' cases, make a difference to these trends.4
Pharmaceutical promotion of SSRIs made much of the claim to have fewer side-effects than the tricyclics, and this contributed to the confidence with which GPs recommended them to patients. In view of the public concern about addictive effects evident in the survey described above, it is ironic that discontinuation reactions are now emerging as a distinct clinical problem (extending to litigation against doctors in the USA), both in SSRIs and in other new anti-depressants like venlafaxine.
The weak construct validity of psychiatric categories, and the dominance of empiricism over theoretical development, are overarching issues for the psychiatric profession.5 Both are apparent in the discourse about depression. So, too, is a lack of explicit reflection on the ideological and societally-framed nature of medical practice, which would need to take account of cultural shifts in attitudes to adversity and the emergence of an expressive, less stoical individualism.6 The surge in anti-depressant prescribing is as much a cultural trend as a medical one, reflecting the rise of a medicalization and professionalization of everyday life and its problems across Western societies.7
There is also an important international dimension. `Depression' is said to contribute 12% of the total burden of nonfatal global disease.8 The World Health Organization describes it as an epidemic that within two decades will be second only to cardiovascular disease in terms of global disease burden. But `depression' has no exact equivalent in non-Western cultures, not least because these do not share a Western ethnopsychology that defines `emotion' as internal, often biological, unintentioned, distinct from cognition, and a feature of individuals rather than situations.9 Non-Western peoples would tend to see the problem in situational and moral terms (as some Western citizens still do, as evidenced by the survey described above), though when they migrate to the West they become more likely to ascribe to a depression-as-disease model.10 This is to highlight the work of culture and its opinion formers—including the medical profession—in shaping a particular interpretation of the world.
Thus the use of Western-derived quantitative instruments to estimate population prevalences worldwide is likely to commit a category fallacy, which is the assumption that mental and bodily state phenomena mean the same thing in whatever setting they are detected. There is no such thing as depression, if by this we mean (as the WHO appear to mean) a unitary, universally valid, pathological entity requiring medical intervention. Such claims seem a serious distortion, one serving to deflect attention away from what millions of people might cite as the basis of their misery, like poverty and lack of rights. The one clear-cut beneficiary would be the pharmaceutical industry, with its vested interest in the biologization of the human predicament.
REFERENCES
Jadhav S. Cultural origins of Western depression. Int J Soc Psychiatry1996; 42:269 -86[Abstract/Free Full Text]
Priest R, Vize C, Roberts A, Roberts M, Tylee A. Lay people's attitudes to treatment of depression: results of opinion poll for defeat depression campaign just before its launch. BMJ1996; 313:858 -9[Abstract/Free Full Text]
Moncrieff J. The anti-depressant debate. Br J Psychiatry 2002;180:193 -4[Free Full Text]
National Institute for Clinical Excellence. Depression: Management Of Depression In Primary and Secondary Care. London: NICE, 2004
Pilgrim D, Rogers A. Social psychiatry and sociology. J Mental Health 2005;14:317 -20
Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatry category. BMJ2001; 322:95 -8[Free Full Text]
Summerfield D. Cross-cultural perspectives on the medicalisation of human suffering. In: Rosen G, ed. Posttraumatic Stress Disorder. Issues and Controversies. Chichester: John Wiley,2004 : 233-45
Ustun T, Ayuso-Mateos J, Chatterji S, Mathers C, Murray C. Global burden of depressive disorders in the year 2000. Br J Psychiatry 2004;184:386 -92[Abstract/Free Full Text]
Lutz C. Depression and the translation of emotional worlds. In: Kleinman A, Good B, eds. Culture And Depression. Studies In The Anthropology And Cross-Cultural Psychiatry Of Affect and Disorder. Berkeley: University of California Press,1985 : 63-100
Karasz A. Cultural differences in conceptual models of depression. Soc Sci Med2005; 60:1625 -35[Medline]
Monday, 9 March 2009
Globalization and Depression
Depression and Globalization: The Politics of Mental Health in the Twenty-First Century
By Carl Walker
203 pp, $69.95
New York, NY, Springer, 2007
ISBN-13: 978-0-3877-2712-7
JAMA. 2008;300(17):2065-2066.
Depression is an internal and inward-looking state. Although clinicians and researchers have long recognized the influence of external factors on mood disorders, they typically consider immediate externalities: a patient's shrunken social supports, troubled relationships, or job loss.1 Walker, a British health psychologist, expands his readers' outlook by considering how macropolitical trends affect depression. He describes the malign political, economic, and social consequences of the political climate shift in the United States and United Kingdom since around 1979 and links this to worsening depression. Walker criticizes mental health professionals for having "focused too much on the individualistic and dispositional factors that we feel we can control and [having] neglected the social and political context within which we all operate" (p viii). By ignoring the patient's broader context, Walker implies, the clinician misses the deforestation for the tree.
Walker argues that the world, particularly the United Kingdom and the United States, has become a worse place to live since 1980. The ideological shift of Thatcher and Reagan has promoted free-market fundamentalism, "ultra-capitalism" (p 98) and deregulation, "seeking short-term profit maximization at the expense of long-term social and industrial success" (p 100), and emphasizing the selfish interests of individuals and businesses over the wealth of the community. This Anglo-American movement, which continues unabated nearly 30 years later, has worsened inequality of wealth, poverty, social services, and quality of life. Deregulation has freed corporations to pursue cheap labor, thereby lowering job security, hurting the poor, and allowing multinational conglomerates either to escape national laws or to alter them in their favor. Corporate officials have infiltrated key government posts. Corporations bombard the public with advertising, bias the news, and infect US school curricula (pp 114-116). The business elite profit; the many, reduced to "employable units" (p 155), pay the price.
The consequences of this consumerist trend include the fragmentation of community and family cohesion as well as the increased isolation of television-watching individuals. Many are more helpless. Minorities and women are especially affected. Inasmuch as social stressors can trigger and prolong depression whereas social supports can protect against it, the stresses of poverty as well as social inequality are risk factors for major depression. This strong and disturbing argument is a humane screed. Would that Walker argued more clearly. This polemic, cast in clotted, frustratingly awkward, repetitive prose, takes two-thirds of the densely written book to develop. The scholarship is suspect, with sparse references—roughly 1 per page—often citing popular books, newspapers, or reviews rather than specific studies. Interpreting the many unreferenced or underreferenced statistics is difficult. Walker conflates depression with other psychiatric illness when it serves his case. The writing is dotted with solecisms, misspellings, and errata. Although the author clearly hopes to rally the community and labor, this alas is no clarion call.
Walker's critique is impassioned but not always logical. His anger at certain politicians and tycoons is palpable, his macroargument often abstract and extreme. Zeal risks zealotry. The burden of depression is indeed increasing,2 and Walker is surely correct to observe society's depressogenic turn, but to ascribe all change to these sociopolitical trends oversimplifies a complex disorder and a complex world. Readers would hardly guess from this jeremiad that depression affects the upper classes or that previous eras have had considerable mental health problems.
The book begins with a muddled discussion of depression as psychiatric illness, abbreviating neuroscience in a paragraph or two and offering a nonclinical description of antidepressant treatments. This chapter may confuse as much as enlighten. Walker does urge readers to recognize major depression as a crippling disease. Chapter 2 hurriedly reviews the historical stigma of depression, rushing through centuries so tumultuously that the Roman physician Galen is discussed along with the Dark and Middle Ages. Walker seems unduly pessimistic about the decline in recent decades of the stigma of depression. The Anglo-American individualistic work ethic, he notes, magnifies the depressed individual's sense of being weak, lazy, and "un-American" (p 44).
Chapter 3 provides a pocket sociopolitical history from Victoria to the 1980s rise of "the New Right." Chapter 4 describes globalization, the hegemony of international corporations, and their social costs. How socioeconomic-political forces might increase the burden of mental illness does not emerge until chapter 5. In chapter 6, Walker scathingly indicts "the depression industry." Psychology is rendered into a pseudoscientific distraction from social forces, misleadingly "substituting the personal for the political" (p 162). The "depression industry" provides "tacit support for the political system that creates such harmful circumstances in the first place" (p ix). Therapists, like corporations, fill consumers' "empty selves" (p 110), a "commodification of empathy and listening" (p 170). Economics, not science, lies behind the development of reliable diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (Third Edition)3 (p 161); such diagnoses are "constructions . . . of ideology" (p 162). This assertion partly contradicts Walker's earlier espousal of depression as an illness. His tired, simplistic, Szaszian socialist approach misprizes the scientific method. Pharmaceutical companies, an inviting target, receive a milder, historically confused critique.
What can be done? Recalling the progressive antitrust movement of the Gilded Age, Walker calls for political engagement, community bonding, governmental regulation (p 186), better housing, and reduced wealth inequity. He invokes continental European social democracy as a kinder capitalism.
One measure of a book is its effect on the reader's outlook. Although Depression and Globalization obliquely addresses clinical depression, I found while reading it that I began to listen to depressed patients differently. I felt newly attuned to the alienating effects of consumerist society on their lives, on its disruption of their family and social lives. What chance has a social scientist's small, flawed book from an academic press against corporate-controlled media conglomerates? Particularly when his message, however heartfelt, is poorly articulated? It is a hoarse voice in the corporate wilderness, but readers should pay it heed.
Financial Disclosures: Dr Markowitz has authored and edited several books on depression for which he receives royalties.
John C. Markowitz, MD, Reviewer
New York State Psychiatric Institute
New York, New York
jcm42@columbia.edu
http://jama.ama-assn.org/cgi/content/full/300/17/2065
By Carl Walker
203 pp, $69.95
New York, NY, Springer, 2007
ISBN-13: 978-0-3877-2712-7
JAMA. 2008;300(17):2065-2066.
Depression is an internal and inward-looking state. Although clinicians and researchers have long recognized the influence of external factors on mood disorders, they typically consider immediate externalities: a patient's shrunken social supports, troubled relationships, or job loss.1 Walker, a British health psychologist, expands his readers' outlook by considering how macropolitical trends affect depression. He describes the malign political, economic, and social consequences of the political climate shift in the United States and United Kingdom since around 1979 and links this to worsening depression. Walker criticizes mental health professionals for having "focused too much on the individualistic and dispositional factors that we feel we can control and [having] neglected the social and political context within which we all operate" (p viii). By ignoring the patient's broader context, Walker implies, the clinician misses the deforestation for the tree.
Walker argues that the world, particularly the United Kingdom and the United States, has become a worse place to live since 1980. The ideological shift of Thatcher and Reagan has promoted free-market fundamentalism, "ultra-capitalism" (p 98) and deregulation, "seeking short-term profit maximization at the expense of long-term social and industrial success" (p 100), and emphasizing the selfish interests of individuals and businesses over the wealth of the community. This Anglo-American movement, which continues unabated nearly 30 years later, has worsened inequality of wealth, poverty, social services, and quality of life. Deregulation has freed corporations to pursue cheap labor, thereby lowering job security, hurting the poor, and allowing multinational conglomerates either to escape national laws or to alter them in their favor. Corporate officials have infiltrated key government posts. Corporations bombard the public with advertising, bias the news, and infect US school curricula (pp 114-116). The business elite profit; the many, reduced to "employable units" (p 155), pay the price.
The consequences of this consumerist trend include the fragmentation of community and family cohesion as well as the increased isolation of television-watching individuals. Many are more helpless. Minorities and women are especially affected. Inasmuch as social stressors can trigger and prolong depression whereas social supports can protect against it, the stresses of poverty as well as social inequality are risk factors for major depression. This strong and disturbing argument is a humane screed. Would that Walker argued more clearly. This polemic, cast in clotted, frustratingly awkward, repetitive prose, takes two-thirds of the densely written book to develop. The scholarship is suspect, with sparse references—roughly 1 per page—often citing popular books, newspapers, or reviews rather than specific studies. Interpreting the many unreferenced or underreferenced statistics is difficult. Walker conflates depression with other psychiatric illness when it serves his case. The writing is dotted with solecisms, misspellings, and errata. Although the author clearly hopes to rally the community and labor, this alas is no clarion call.
Walker's critique is impassioned but not always logical. His anger at certain politicians and tycoons is palpable, his macroargument often abstract and extreme. Zeal risks zealotry. The burden of depression is indeed increasing,2 and Walker is surely correct to observe society's depressogenic turn, but to ascribe all change to these sociopolitical trends oversimplifies a complex disorder and a complex world. Readers would hardly guess from this jeremiad that depression affects the upper classes or that previous eras have had considerable mental health problems.
The book begins with a muddled discussion of depression as psychiatric illness, abbreviating neuroscience in a paragraph or two and offering a nonclinical description of antidepressant treatments. This chapter may confuse as much as enlighten. Walker does urge readers to recognize major depression as a crippling disease. Chapter 2 hurriedly reviews the historical stigma of depression, rushing through centuries so tumultuously that the Roman physician Galen is discussed along with the Dark and Middle Ages. Walker seems unduly pessimistic about the decline in recent decades of the stigma of depression. The Anglo-American individualistic work ethic, he notes, magnifies the depressed individual's sense of being weak, lazy, and "un-American" (p 44).
Chapter 3 provides a pocket sociopolitical history from Victoria to the 1980s rise of "the New Right." Chapter 4 describes globalization, the hegemony of international corporations, and their social costs. How socioeconomic-political forces might increase the burden of mental illness does not emerge until chapter 5. In chapter 6, Walker scathingly indicts "the depression industry." Psychology is rendered into a pseudoscientific distraction from social forces, misleadingly "substituting the personal for the political" (p 162). The "depression industry" provides "tacit support for the political system that creates such harmful circumstances in the first place" (p ix). Therapists, like corporations, fill consumers' "empty selves" (p 110), a "commodification of empathy and listening" (p 170). Economics, not science, lies behind the development of reliable diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (Third Edition)3 (p 161); such diagnoses are "constructions . . . of ideology" (p 162). This assertion partly contradicts Walker's earlier espousal of depression as an illness. His tired, simplistic, Szaszian socialist approach misprizes the scientific method. Pharmaceutical companies, an inviting target, receive a milder, historically confused critique.
What can be done? Recalling the progressive antitrust movement of the Gilded Age, Walker calls for political engagement, community bonding, governmental regulation (p 186), better housing, and reduced wealth inequity. He invokes continental European social democracy as a kinder capitalism.
One measure of a book is its effect on the reader's outlook. Although Depression and Globalization obliquely addresses clinical depression, I found while reading it that I began to listen to depressed patients differently. I felt newly attuned to the alienating effects of consumerist society on their lives, on its disruption of their family and social lives. What chance has a social scientist's small, flawed book from an academic press against corporate-controlled media conglomerates? Particularly when his message, however heartfelt, is poorly articulated? It is a hoarse voice in the corporate wilderness, but readers should pay it heed.
Financial Disclosures: Dr Markowitz has authored and edited several books on depression for which he receives royalties.
John C. Markowitz, MD, Reviewer
New York State Psychiatric Institute
New York, New York
jcm42@columbia.edu
http://jama.ama-assn.org/cgi/content/full/300/17/2065
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