Depression: the Power of Diagnosis

By Jonathan Sadowsky, Case Western Reserve University

Julia Knopes is a medical anthropologist with Bipolar Disorder.[1] During her academic training, she became well-versed in the critical literature on psychiatry and mental health, particularly the critique of biomedical psychiatry. Psychiatric diagnostic labels, according to much of this literature, are cultural constructions that enforce social norms, and psychopharmaceuticals are a product of a biologically reductionist paradigm that obscures the social context of distress.

As Julia was completing the write-up of her dissertation—a study of medical students in cadaver labs—she went into a manic phase. She was loathed to seek out psychiatric help. What medical anthropologist would want her distress bandaged over with a reductive label or her social context obscured by a medication? Shortly after completing her dissertation, though, Julia crashed into depression. By her account, she could barely function during the depression. Ultimately, she felt she had no choice but to seek medical help. The psychiatrists she saw provided medication. They were also, to her surprise, interested in her social context, and by no means wanted to send her home with a prescription without gaining a rich understanding of her life situation. She has been on medications steadily since then, feels much healthier, and is grateful for the treatment.

As a historian of psychiatry, I am also versed in critical literature. I have even contributed to it. I have written about the losses that can be entailed when a person’s distress is reduced to a diagnostic label, and about the dangers of biological reductionism. I open with Julia’s story because it helps to explain one of my motivations for writing my new book The Empire of Depression, and why I wrote it the way I did.[2] The history of depression is fraught with social meaning and cultural complexity, and I hope I showed that in the book. I also wanted to show that while psychiatry can be an instrument of power—discursive, legal, and political—it is also a form of medicine, and can do what medicine is supposed to do: relieve suffering and give hope.

The historical and social science literature on depression is now bursting with lamentations about over-diagnosis and over-medicalization, even as the World Health Organization sounds alarms about the ubiquity of the ailment, its global reach, and its contribution to overall debility.[3] It is also commonplace now to note that “depression” is an amorphous category, whose borders from the ordinary and inevitable sadness in life are shifting and contested. My concern with these arguments is not that they are wrong. They raise valid points that are pursued in my book. My concern is that putting the spotlight solely on these dangers leaves any usefulness of the diagnosis and its medical treatment in the dark.

I open the book by showing depression is indeed hard to define, and how tangled debates are over when depression should count as an illness state—and what is an illness. I then discuss melancholia, which not long ago was considered self-evidently the precursor to depression in the European tradition, though some historians now stress the discontinuities and differences between the two labels.[4] Then I turn to the history of depression in psychoanalysis—a history that began before Freud gave the subject much attention and continues with innovations long after his literal death in 1939, and his alleged metaphorical death the day the F.D.A. approved Prozac. In the latter half of the book, I trace the many developments that accompanied the transformation of depression into a common diagnostic category—rating scales and epidemiological study, new psychotherapies, the ever-changing DSM, and of course the rise of antidepressants. I also emphasize, more than most historians so far have, that depression is an illness of social inequality and adversity. But I also insist that this is not by itself a reason to reject a “medical model” of depression, any more than recognizing the effects of social inequality on tuberculosis or COVID-19 means we should take those ailments out of the domain of medicine. And, as in my previous work, I sought some immersion where possible in the self-representation of the people in pain, and close the book with an analysis of depression memoirs.

The Empire of Depression offers a qualified defence of psychiatric diagnostic labelling. Historians of psychiatry have amply documented how psychiatric diagnoses can be arbitrary, oppressive, and culture-bound reinforcing invidious social norms and status differences. Too often, this is taken as a reason to treat all psychiatric diagnoses as only these things.[5]

One way some have tried to show that depression, or any other mental illness, is a valid diagnostic label is to show that it is found across all, or at least many, cultures. This does not follow, since an illness that is found in only one culture is no less illness because of that. Still, universality is a part of what I call the rhetorical “tactics of realness.”[6] It’s a hard point to prove either way, though. An idea of how hard it is can be in the work of T. A. Lambo, the luminary Nigerian psychiatrist who did so much to shape cross-cultural study. In just seven years, Lambo took three different positions on whether depression was prevalent among the Yoruba, at first saying that Yoruba cultural patterns protected against depression, later thinking it was prevalent but misdiagnosed as neurasthenia, and then concluding that the symptoms of depression were widespread, but perhaps not coalesced into a distinct illness category.[7] Sushrut Jadhav has called depression the single most fraught psychiatric category for cross-cultural study.[8] As I put it in the book, that is quite a statement, given that they are all fraught. Even as the WHO sees rising global rates of depression, others argue that depression is, in fact, a Western culture-bound syndrome.[9]

I cover the complexity of this debate in more detail in the book; here, I want to stress two things. One is that even if you do regard depression as a universal human illness category, you still need to reckon with Western (and, increasingly, cosmopolitan) psychiatry as culture itself, one that figures depression in particular ways. For example, it tends to foreground biological causes of depression. Depressive illness is considered in many parts of the world to be a response to social stress. Ironically, Western psychiatry simultaneously tends to downplay physical symptoms of depression, and foreground the affective dimension.

The second thing I want to stress about the cross-cultural debate over depression is how deep its historical roots go. The question did not suddenly arrive with the advent of antidepressants. It has roots in ideas of racial difference that are part of the history of Western imperialism, and a colonial ideology that European superiority created a capacity for depression. Or, put the other way, colonial ideology held that non-European races were not developed enough to have depression. These ideas date back at least to the early nineteenth century.

Universalizing psychiatric categories carry risks, of flattening out cultural differences. Colonial psychiatry’s use of Western labels was certainly not a useful lens for understanding the predicaments of the patients that were housed in the dismal colonial asylums. But we should also consider the risks of over-emphasizing differences. The transcultural psychiatry that emerged in the early post-colonial period may have at times been overly homogenizing, but it was working against a deeply “othering” colonial psychiatry that assumed incommensurable differences.

The history of colonial ideology may seem removed from the opening story about Julia Knopes. They are related, though. Much critical study of psychiatry is animated by an antipsychiatric ethos. We need to think critically about what we even mean when we say “critical.” The colonial psychiatric diagnosis did flatten out both cultural differences and individual experiences. That was at least in part precisely because it was colonial. Demonstrating this does not mean that this is the essence of what psychiatric diagnosis does. Similarly, biological psychiatry may be reductive, or at least may be practised in reductive ways, When that happens, it warrants our criticism. Any outright rejection of a “medical model,” though, is just as one-sided. Too often, taking a critical stance towards psychiatry has meant taking a relentlessly negative one. And too often, exhortations about “listening to patients” means exclusively listening to patients who challenge psychiatry, and not those who report benefits.

Psychiatric diagnosis may be an exercise of power. But, as colonial psychiatry reveals, withholding a psychiatric label can also be an exercise of power.

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[1] This is her real name. Her story is used here with her permission and even encouragement. I of course gave her the option of being anonymized, but her preference was that she be identified.

[2] Jonathan Sadowsky, The Empire of Depression: A New History (London: Polity Books, 2020). The histories of bipolar disorder and unipolar depression are related, but in the interest of manageable focus, my book emphasizes unipolar depression.

[3] http://www.who.int/mediacentre/news/releases/2017/world-health-day/en/. Accessed July 7, 2017.

[4] In my opinion, many now over-stress the discontinuities. I’m not going to get into that here—read the book!

[5] I am more convinced by the nuanced view Felicity Callard has sketched; Felicity Callard, “Psychiatric Diagnosis: The Indispensability of Ambivalence,” Journal of Medical Ethics 40 (2014) 526-530.

[6] The other tactics include appeal to antiquity (“if depression is found a long time ago it must be real”) and analogy to physical illnesses whose objective reality engenders less scepticism (“depression is a disease, just like diabetes”).

[7] Empire of Depression, 13-14.

[8] Sushrut Jadhav, “The Cultural Construction of Western Depression,” in Vieda Skultans and John Cox, Anthropological Approaches to Psychological Medicine (Philadelphia: Jessica Kingsley Publishers, 2000).

[9] For example, Christopher Dorwick, “Depression as a Culture-Bound Syndrome: Implications for Primary Care,” British Journal of General Practice 63, 610 (2013) 229-230. Matthew Bell, Melancholia, The Western Malady (Cambridge: Cambridge University Press, 2014).