This month’s issue of The British Journal of General Practice contains an editorial “Depression as a culture-bound syndrome: implications for primary care” by Dr. Christopher Dowrick, Professor of Primary Medical Care at the Institute of Psychology, Health, and Society of the University of Liverpool. Dr. Dowrick claims that depression “fulfills the criteria for a culture-bound syndrome,” i.e. , one of the “’illnesses’, limited to specific societies or culture areas, composed of localized diagnostic categories,” like, for instance ataque de nervios in Latin America. In the case of depression the culture area affected is “westernized societies.” Putting the word “illness,” when applied to culture-bound syndromes into quotation marks indicates that Dr. Dowrick does not consider such syndromes real illnesses; it follows that depression--a culture-bound syndrome of westernized societies--is also not a real illness. Dr. Dowrick further argues that depression as a diagnostic category cannot be seen as “a universal, transcultural concept,” because it has no validity and utility, and it does not have validity and utility, because “there is no sound evidence for a discrete pathophysiological basis” for depression. I find myself in absolute agreement with Dr. Dowrick’s two specific statements above (that depression is a culture-bound syndrome of westernized societies, and that there is no discrete pathophysiological basis for this diagnostic category), and yet completely disagree with the implication that depression is not a real disease.
It is important to remember what a disease, or illness, in general, is. Both terms clearly focus on the personal, subjective experience of suffering: dis-ease as opposed to ease, illness as opposed to wellness. So does the word “pathology,” which derives from the Greek for “suffering” (pathos) and Greek for “knowledge” or “understanding” (logos). Thus pathology = understanding of suffering. Even health professionals, whose task is to alleviate suffering, first of all, often forget this, and think that “pathology” refers not to the understanding of the patient’s suffering, but to an objective morbid condition underlying it, and also equate “disease” and “illness” with such objective morbid condition. Moreover, they also believe that such objective morbid condition is necessarily material, i.e., biological. As a result, the absence of “a discrete pathophysiological basis” for depression can lead Dr. Dowrick to the conclusion that depression is not a real illness, but a category, invented for commercial and professional reasons of pharmaceutical companies and medical practitioners who want to get paid for services rendered, which was developed on the basis of “an ethic of happiness, within which aberrations from the norm are assumed to indicate illness.” But, as my previous post [The Real Trouble With DSM-5] argued, mental diseases are likely to be caused by culture, rather than biology, because the mind, or the mental process, while occurring in the brain, is mostly processing intakes from the cultural, symbolic environment, in which it is unlike digestion or breathing, which process intakes from the material, physical and organic, environment. There is an objective underlying condition for the disease (i.e., the suffering) of depression, but this condition is cultural: it is the cultural condition of anomie, caused by the openness of modern Western societies and the bewildering multiplicity of choices for possible self-definition they offer their members [see The Modern Mental Disease]. Depression is, indeed, a culture-bound syndrome and at the same time it is a terrible disease, which cannot and should not be equated with low or bad mood, sadness, or any other “aberration from the norm of happiness”: it differs from these normal mental states symptomatically in the intensity of suffering experienced, in its character (such as resistance to distraction and other symptoms of the paralysis of the will, expressed among other things in the characteristic lack of motivation), and in its functional effects. An occasionally sad person is not dysfunctional, a depressed one is--depression destroys relationships and renders one incapable of performing one’s duties, it is as real and serious a handicap as any physical one. Neither should depression be seen as an exaggeration of normal mental states, differing from them only quantitatively, or equated with normal reactions to particularly traumatic life events, such as bereavement. (Indeed, Dr. Dowrick, like many other critics, justly castigates DSM-5 for including in the depressive diagnosis grief lasting more than two weeks--as if it were normal, in either statistical or medical sense of the word, to fully adjust to the loss of a close family member in two weeks!) One of the central characteristics of depression--and an exacerbating factor of the suffering it causes--is precisely its lack of connection to specific life events. As anyone who has experienced depression or observed closely persons suffering from depression knows, this absence of an external cause often leads the suffering individual to suspect oneself of madness. The most characteristic feature of severe depression, expressive of the intensity of suffering associated with it, is suicidal thinking. Twenty percent of people suffering from depression eventually commit suicide, which makes it one of the deadliest diseases today. It would be quite irresponsible of a health professional to let the lack of a “discrete pathophysiological basis” obscure this.
Because depression is a real disease, severe and often lethal, it requires the attention of a health professional. Because the causes of depression are cultural, it stands to reason that methods used for the treatment of physical diseases won’t be successful in its treatment. This does not mean that medications won’t have any effect. Pharmaceutical substances are powerful agents, just like alcohol or recreational drugs, and will influence the chemical balance in the brain, sometimes wreaking havoc in it and sometimes alleviating some of the symptoms. But even when the effects of medications are positive, they won’t address the cause of the disease. That’s why, so far, depression has no cure. It is a recurrent, or chronic, illness. Dr. Dowrick suggests that the primary physician serve as a spiritual advisor of sorts to the patient who comes to the clinic with such a mental complaint, talk to such a patient about life problems, ask about the patient’s “physical, psychological, and social circumstances…propose ideas for change… offer hope of an alternative.” But this, while a reflection of kindness and sympathy, is similar to treating cancer with cold compresses, the medication being physical like the disease, unlikely to cause any damage, but also totally irrelevant. Depression has an objective cause; to cure the disease, the therapy, just like in cancer, must focus on this objective cause and neutralize it. In depression, unlike in cancer, this objective cause is cultural. In the case of cancer, a responsible primary physician will refer the patient to an oncologist. In the case of depression, the physician must refer the patient to a specialist who understands the cultural causes of this awful disease and can treat it. There are no such specialists today. Psychiatry must recognize the cultural causes of depression and make cultural expertise an essential element of its therapeutic arsenal. Depression is a culture-bound syndrome. It is also a terrible real disease. It can be cured. But we must at last open our eyes to its cultural causation.
Liah Greenfeld is the author of Mind, Modernity, Madness: The Impact of Culture on Human Experience