The World Federation for Mental Health proposes that depression is a global crisis because it affects more than 300 million people around the world, that it is associated with profound social and economic consequences, and that despite the fact that it is “treatable” most people around the world do not receive these treatments. But there are many who question this evidence, with the most strident critique challenging the very notion of depression as a disorder in the first place and equating its application across cultures with psychiatric imperialism: one commentator has famously referred to the globalisation of the concept of depression as the >“Americanisation of mental illness”. (http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html?pagewanted=all).
These dissenting voices argue that what constitutes depression is, in fact, a perfectly normal human response to adversity in one’s life (for example, losing someone you love or your job), and that applying a medical label wrongly transforms this response into a sickness. Worse, applying such labels primarily furthers the pernicious agendas of the professional mental health sectors and its bed-fellows in the pharmaceutical industry. As Horwitz and Wakefield, two American mental health professionals argue, there is a real danger of the >“loss of sadness” (http://www.amazon.com/Loss-Sadness-Psychiatry-Transformed-Depressive/dp/0195313046), an emotional experience which is as common as happiness, through the over-use and abuse of the diagnostic label of depression and antidepressant medicines.
What do we make of these contrasting views? Is depression a real disorder? Does it really occur in non-western settings? How do we distinguish despair from disorder?
There seems little doubt in my mind that depression, in particular at the severe end of the experience of this condition, is as real a disorder as diabetes is at the severe end of blood glucose levels. I could invoke the hundreds of studies carried out in scores of countries around the world which demonstrate not only that the core features of this condition can be identified in all cultures, but also that the condition is very common and disabling. I could invoke the fact that my own mother who grew up and lived her life in India, suffered from severe depression from which she made a full recovery with treatment. But I think the most compelling evidence to support the existence of this condition comes from the annals of the history of medical knowledge: indigenous systems of medicine from times immemorial, including our own in India, have described a syndrome akin to what we refer to as depression (albeit with different names and different explanations). Depression has existed as long as mankind itself, and certainly well before psychiatry, antidepressant medication or the nation of America itself came into being.
However, it is equally true that, we have a real problem is distinguishing depression as an illness from the despair of everyday life. Defining a disorder, at least from a clinical point of view, necessitates that we do identify such a dividing line. While the problem of defining the dividing line is also encountered in many other medical conditions such as hypertension (what is the exact dividing line between “normal” and “abnormal” blood pressure?), at least in those cases we can fall back on some objective indicator or measure (such as a blood pressure reading) to determine whether a person has the condition. In the absence of such an objective indicator of the disorder, psychiatry has defined a “case” on the basis of various characteristics of the self-reported experiences of depression (for example, their duration) and the impact of these experiences on social or occupational functioning. There is an obvious element of subjectivity and arbitrariness in making such distinctions and thus the inherent risk of mistaking despair for disorder, particularly at the milder end of the spectrum.
In the end, I do not think we will find the neat boundary between “normal sadness” and “clinical depression” if only because mood is an innate human characteristic, like weight or the length of our hair. However, to reject the very notion of depression as an illness on account of these difficulties is throwing the baby out with the bathwater. In my mind, depression is, like all non-communicable diseases, a physiologically expressed condition which is profoundly influenced by our social and cultural environments. Depression is a global crisis not only because it is common and universal, but because the vast majority of affected people suffer in silence or receive inappropriate care. We need to move firmly beyond the misinformed views that depression is a “psychiatric invention” to investing more on understanding its nature, finding more accurate ways of distinguishing when a person with the condition may benefit from medical care, and improving access to the full range of treatments (medicines and psychosocial) for such persons.
(Vikram Patel is director of the Centre for Global Mental Health at the London School of Hygiene & Tropical Medicine, director of the Center for Mental Health at the Public Health Foundation of India, and founder of the Goa-based NGO, Sangath.)
