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