What is depression? The answer you usually get from professionals in the mental health business is that depression is what you have if you meet the criteria for major depressive episode (MD) in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). These criteria include, among others, depressed mood, diminished interest or pleasure, fatigue, and so on. There are nine main criteria, and with some additional criteria over 70 combinations of symptoms yelds a depressive diagnose.
But this does not answer the original question, what depression is. The criteria in DSM-IV only describe how to recognize depression, they do not account for any etiology (from greek αἰτιολογία, ‘give reason for’), that is, DSM-IV give no reason or cause for the cluster of symptoms that constitute the diagnose of major depressive episode.
The diagnostic criteria for depression have been criticized (see, for example, Marecek, 2006; Horwitz & Wakefield, 2007; Stoppard, 2000). However, my current interest is this elusive question about what depression is, the question of the ontology of depression. Ontology (from greek ὤν, ‘being’) referes to the metaphysical question of what entities exist and in what way they can be said to exist.
As Stoppard (2000) points out, the definition of ‘mental disorder’ as used in DSM-IV is not really that ‘purely descriptive’ and ‘atheroetical’ as is usually claimed. Most important, a mental disorder is solely defined in terms of something residing within an individual, a ‘manifestation of a behavioral, psychological, or biological dysfunction in the indivual’ (APA, 1994, p. xxi). According to this, the cause of depression and it's mechanisms must be sought within an individual. Although this definition does not exclude social or interpersonal factors, it does certainly exclude the view that depression, as defined by DSM-IV, is but a sociocultural expression of human suffering, an expression that varies with different cultures and different parts of the world (Marecek, 2006).
Thus, the definition of mental disorders used in DSM-IV implies that depression actually exists in some material way in the world. It is some kind of dysfunction within the individual—let it be behavioral, psychological or biological—similar to a medical condition like diabetes, cancer or a broken leg. The big difference, of course, is that there are no objective tests, nothing akin to a blood sample, that can be used to diagnose depression. It can only be inferred through a clinical interview, based on the criteria in DSM-IV and professional judgements.
Stoppard (2000) tend to view depression as a social construction that is created as the clinical interview progresses: ‘depression is discursively constructed as an entity in the course of a particular kind of interpersonal interaction called the clinical interview’ (Stoppard, 2000, p. 30). The point is that the ontology of depression is unclear. It may even be that depression does not exist at all. Viewed as a social construction, depression is but a name for a particular way of expressing human suffering—a way that primarly apply to women in the western world (Tavris, 1992).
Theories of depression is a way of accounting for the etiology of depression. When the origin and course of depression is explained, an answer to the ontological question of depression is explicitly or implicitly proposed (at least for the majority of theories). According to cognitive theories, depression is caused by a particular way of thinking and interpreting the world. According to some psychodynamic theories, depression is caused by repressed loss and anger. According to behavioral theories, depression is caused by learned helplessness and sustained by lack of positive reinforcement. In any case, depression is established as something that actually exist, a particular process within the individual. This, as it happens, is exactly the way DSM-IV defines mental disorders.
Although the diagnostic criteria of depression can be criticized, revised and refined, the very idea of a depressive disorder as DSM-IV defines it does not contradict most theoretical work on depression. Problems arise, however, if depression is viewed as a sociocultural expression of human suffering (or, as Marecek [2006] puts it, ‘depressive suffering’). The very existence of a distinct depressive disorder with some kind of material ontological status must be questioned. Symptoms, as they appear in DSM-IV, must be viewed as a culturally dependent way of naming a particular way of behaving and experiencing the world, a way that does not fit within ‘normality’. Theories of depression, then, is nothing but a way of explaining abnormal behaviour, explanations that have a profound impact on the way ‘depressed’ people are viewed and treated within primary care and mental health professions.
There are several problems with either of these two ontological perspectives. In short, the view that depression is something that actually exists within an individual can be questioned based on cross cultural and anthropological studies. What is called depression in the western world does not exist in all cultures, or is at least rather different from the criteria in DSM-IV (Marecek, 2006). On the other hand, the view that depression is but one of many possible expressions of ‘depressive suffering’ cannot account for the fact that there are some people that seem to suffer from severe and cronic ‘depressive impairment’ for no apparent reasons.
So, what is the ontological status of that phenomenon we call ‘depression’? The most honest answer, at least for the time being, must be: I don't know.
But this does not answer the original question, what depression is. The criteria in DSM-IV only describe how to recognize depression, they do not account for any etiology (from greek αἰτιολογία, ‘give reason for’), that is, DSM-IV give no reason or cause for the cluster of symptoms that constitute the diagnose of major depressive episode.
The diagnostic criteria for depression have been criticized (see, for example, Marecek, 2006; Horwitz & Wakefield, 2007; Stoppard, 2000). However, my current interest is this elusive question about what depression is, the question of the ontology of depression. Ontology (from greek ὤν, ‘being’) referes to the metaphysical question of what entities exist and in what way they can be said to exist.
As Stoppard (2000) points out, the definition of ‘mental disorder’ as used in DSM-IV is not really that ‘purely descriptive’ and ‘atheroetical’ as is usually claimed. Most important, a mental disorder is solely defined in terms of something residing within an individual, a ‘manifestation of a behavioral, psychological, or biological dysfunction in the indivual’ (APA, 1994, p. xxi). According to this, the cause of depression and it's mechanisms must be sought within an individual. Although this definition does not exclude social or interpersonal factors, it does certainly exclude the view that depression, as defined by DSM-IV, is but a sociocultural expression of human suffering, an expression that varies with different cultures and different parts of the world (Marecek, 2006).
Thus, the definition of mental disorders used in DSM-IV implies that depression actually exists in some material way in the world. It is some kind of dysfunction within the individual—let it be behavioral, psychological or biological—similar to a medical condition like diabetes, cancer or a broken leg. The big difference, of course, is that there are no objective tests, nothing akin to a blood sample, that can be used to diagnose depression. It can only be inferred through a clinical interview, based on the criteria in DSM-IV and professional judgements.
Stoppard (2000) tend to view depression as a social construction that is created as the clinical interview progresses: ‘depression is discursively constructed as an entity in the course of a particular kind of interpersonal interaction called the clinical interview’ (Stoppard, 2000, p. 30). The point is that the ontology of depression is unclear. It may even be that depression does not exist at all. Viewed as a social construction, depression is but a name for a particular way of expressing human suffering—a way that primarly apply to women in the western world (Tavris, 1992).
Theories of depression is a way of accounting for the etiology of depression. When the origin and course of depression is explained, an answer to the ontological question of depression is explicitly or implicitly proposed (at least for the majority of theories). According to cognitive theories, depression is caused by a particular way of thinking and interpreting the world. According to some psychodynamic theories, depression is caused by repressed loss and anger. According to behavioral theories, depression is caused by learned helplessness and sustained by lack of positive reinforcement. In any case, depression is established as something that actually exist, a particular process within the individual. This, as it happens, is exactly the way DSM-IV defines mental disorders.
Although the diagnostic criteria of depression can be criticized, revised and refined, the very idea of a depressive disorder as DSM-IV defines it does not contradict most theoretical work on depression. Problems arise, however, if depression is viewed as a sociocultural expression of human suffering (or, as Marecek [2006] puts it, ‘depressive suffering’). The very existence of a distinct depressive disorder with some kind of material ontological status must be questioned. Symptoms, as they appear in DSM-IV, must be viewed as a culturally dependent way of naming a particular way of behaving and experiencing the world, a way that does not fit within ‘normality’. Theories of depression, then, is nothing but a way of explaining abnormal behaviour, explanations that have a profound impact on the way ‘depressed’ people are viewed and treated within primary care and mental health professions.
There are several problems with either of these two ontological perspectives. In short, the view that depression is something that actually exists within an individual can be questioned based on cross cultural and anthropological studies. What is called depression in the western world does not exist in all cultures, or is at least rather different from the criteria in DSM-IV (Marecek, 2006). On the other hand, the view that depression is but one of many possible expressions of ‘depressive suffering’ cannot account for the fact that there are some people that seem to suffer from severe and cronic ‘depressive impairment’ for no apparent reasons.
So, what is the ontological status of that phenomenon we call ‘depression’? The most honest answer, at least for the time being, must be: I don't know.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Marecek, J. (2006). Social suffering, gender, and women’s depression. In C. L. M. Keyes & S. H. Goodman (Eds.), Women and depression: A handbook for the social, behavioral, and biomedical sciences (pp. 283-308). New York: Cambridge University Press.
Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. New York: Oxford University Press.
Stoppard, J. M. (2000). Understanding depression: Feminist social constructionist approaches. London: Routledge.
Tavris, C. (1992). The mismeasure of woman. New York: Simon & Schuster.
Interesting article! I thought I'd post some ideas that entered my head while reading it.
ReplyDeleteFirst of all, the diagnosis Depression is a social concept and therefore to be used by the society to understand and to handle the diagnosis (that society itself created). In order for the society to avoid uncertainty and fear of the unknown the creation of such a concept is necessary.
At the same time, there is a phenomenologically real experience for the individual with the diagnosis. Even though his cognitions about his conditions are socially constructed, there is still the undeniable raw experience of unpleasant 'melancholia' that takes its expression in various physiological sensations. No matter how much we change the definitions or the whole language in general, there is still this core that we cannot remove.
What ‘core’ are you referring to? This is the main problem with the ‘medical model’ of depression: it is difficult to find such a ‘core depressive experience’ that is the same for all people, all over the world, regardless of culture.
ReplyDeleteAnd for the ‘fear and uncertainty issue’, Horwitz and Wakefiled (cited above; their book is translated into Swedish and published last year) makes a point out of the fact that the DSM-IV criteria for depression does not distinguish between ‘normal sadness’ due to some kind of loss, and ‘pathologic depression’ without any obvious cause. DSM-IV has a little caveat about ‘the loss of a loved one’, but that will be removed in DSM-IV.
ReplyDeleteThey (and many others) claim that this ‘medicalization’, that is, treating non-medical problems as medical disorders, is the reason why the prevalence of depression have virtually exploded over the last 20 years.
I think that the ontology (and epistemology) of depression can only be located in the interaction between the individual and his socio-cultural environment. The sociosis that every community seems to develop (Van den Berg 1961), calls for an appropriate reply from the inside of each community member. That constitutes politics of one of two kinds.
ReplyDeleteI believe that how a community develops its own biases towards the truth, can be complemented by each of its members' ability to correct that (as well as worsen it). If truth is what can be detected by independent confirmation, then the two politics mentioned are independent rejection of enemies (groupsism) and dependent confirmation of friends (cronyism). Their tidal wave would be dependent rejection, reminding strongly of power-distance (Mulder 1972, Hofstede 2004).
It is this return to the more or less ancient ways of science, justice and journalism that can heal and take away depression imho.
Thank you for your post, Ron. I find it very interesting, but I must admit that I don't know much about Jan Hendrik van den Berg and his concept of sociosis, which, as far as I understand (which isn't very far!) is a kind of social attribution of neurosis, that is, neurosis is not seen as an individual phenomenon, but a kind of social pathology.
ReplyDeleteThere are, of course, social theories of depreession. What I insist on trying to do, is separationg the ontology (or metaphysics) of what we call depression (which, of course, can be a social phenomenon) from the concept or construct itself.
I theorize about the general categories of disorders that mental health professionals have found, de-realization and de-personalization, believing them to be caused by sociosis on the one hand and to be rooted in ontological and epistemological assumptions about what truth is. Discussion is going on here: http://forum.philosophynow.org/viewtopic.php?p=90045#p90045
ReplyDeleteWhat I mean by 'core' is not that there is a core common for every case of depression, of which there evidently is none. What I mean is that to find the ontology and hence try and go beyond sociology, we are left with the physiological sensations associated with the diagnosis. This obviously makes it difficult to know that we are really talking about depression when discussing only the physiology, since depression necessarily involves also the cognitive (and therefore socially constructed) aspects.
ReplyDeleteI think of the inability of children to distinguish their stomach ache from what adults call anxiety or sadness.
The problem is then that when we want to know what depression really is, as separate from its sociological context we automatically lose half the concept, since depression de facto is a sociological concept.
Emil, first, don't confuse the theory of cognitive constructivism with the epistemology of social construction! This is a common mistake that we psychologists often do. See my post ‘Den förvirrande stridslinjen mellan positivism och social konstruktionism’ on my Swedish blog.
ReplyDeleteWhen I read your comment, I actually think that we agree. You say that ‘depression de facto is a sociological concept’, which I interpret as saying that depression is a ‘social construction’. The question, then, is if what we call depression is a pure construction with no real existence (that is, a reification of the concept of depression), or if depression is a social construction built on something that actually exists—although expressed and understood in different ways in different parts of the world.
Can we ever know for certain? At the end of the day, maybe all this comes down to faith?