Wednesday, October 5, 2011

On the ontology of depression

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.


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.