Generation Meds

How antidepressants cheered us up, let us down, and changed who we are.

Rethinking Stigma

To reduce stigma, must we see disorder as 'a flaw in chemistry, not character'?

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In my last post, I wrote about Ridge Diagnostics and their new blood test that can predict whether a patient qualifies for a DSM-IV diagnosis of depression.

In my reading about the test, I came across this quote from Ridge's chief scientific officer, John Bilello. Speaking of the test, Bilello said he hopes that "the biological basis of this test may provide patients with insight into their depression as a treatable disease rather than a source of self-doubt and stigma."

On the face of it, that's a pretty typical remark. The word "stigma" comes up again and again in the conversation about depression and other mental disorders. Often it's used by psychiatrists or others inside the mental health care system, as part of an argument much like the one that John Bilello makes here. The more that people can understand mental disorder as a biological phenomenon, the reasoning goes, the less they will suffer from stigma.

Actually, this is a remarkable argument, and it's worth taking a little time to unpack it.

Let's start with the dictionary. What is this "stigma," anyway? At its root, the word means a sign or a mark. In the 1950s, the sociologist Erving Goffman brought the word into the vocabulary of social science. He used it to mean the taking-on or the imposition of an identity that marks its bearer as being different from other people.

Let's bracket that out for a second and return to Bilello's quote. "The biological basis of this test may provide patients with insight into their depression as a treatable disease rather than a source of self-doubt and stigma."

Bilello links the idea of having a biological disease to the idea of freedom from stigma. He implies that there is some other way we could see depression—as something non-biological and non-treatable—that would inherently involve more stigma.

In this move, he's referencing an idea that lies behind all similar arguments about stigma and depression. It's the idea that a long time ago, before depression was recognized as a physical disease, it was seen as something else, something more closely integrated with an individual's personality. (Sometimes people who refer to this idea directly use the phrase "character flaw," as in, "Depression is a flaw in chemistry, not character.")

There's certainly a germ of truth in this account. In the Middle Ages, symptoms of depression were to some extent regarded as a sin, and as such, were a source of extra guilt and shame for the depressed person. In many times and places, including the mid-twentieth century before modern psychiatry's biomedical turn, depression was seen not as "biological" but as "psychological."

We used to imagine depression as the result of an individual's personality structure interacting with his or her life circumstances. Now we imagine it as "a disease like diabetes," striking at random from outside. And many people who are close to the issue think it's vital that we see it the second way. Only by understanding depression as disease-like, they insist, can we rid it of the stigma it once carried.

The problem is that this argument doesn't make sense.

There is actually no reason why understanding mental disorder as a physical phenomenon should lessen the stigma of having a mental disorder. Having a physical disease can 'mark' someone as different just as much as having a certain kind of personality. Whether or not negative meaning attaches to this difference is an entirely separate question.

I don't mean to suggest that the stigma argument isn't well-meant. Most of the time, it is. I agree in spirit: people with depression feel bad and guilty enough, and there's no reason to make them feel any more so.

But I vehemently disagree with the idea that informing people with depression that they're suffering from "a real, physical disease" is the way to bring them greater peace of mind, to make them feel less marked or singled out.

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Given that we don't know exactly what depression is—and we certainly haven't proven that it's a disease or even clarified what we mean by "chemical imbalance"—we should not be heavy handed in assuming what way of talking about depression is going to free people from stigma.

For example, why should it be more socially comfortable to think of oneself as having a congenitally malfunctioning brain, a "flaw in chemistry," than it is to think of oneself as 'going through a rough patch,' or even as having a relatively Saturnine disposition? In the last two cases, at least the depressed person can enjoy the comfort of believing that she feels bad for a reason. She can continue to make sense to herself.

In fact, seeing depression as a physical disease may make matters worse—for depressives themselves, and for the people in their lives. As the journalist Ethan Watters wrote in his book Crazy Like Us: The Globalization of the American Psyche, numerous cross-cultural studies have indicated that in culture where people think of mental illness as physical or genetic in origin, they are more likely to be fearful  of the mentally ill and less likely to want contact with them than in cultures where people think of mental illness as caused by a person's situation, environment, or even inner self.*

With depression and other mental disorders, some stigma—in the sense of 'difference'—may be inevitable. What we can do, and what the makers of the stigma argument, to their credit, really want to do, is not to heap negative value on that difference. The truth is that's a goal we can strive for no matter what model of depression we use.

*Watters, Crazy Like Us, page 173.

Katherine Sharpe is the author of Coming of Age on Zoloft.

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