Is global mental health the ‘Americanization of mental illness’?
Vikram Patel is a Wellcome Trust Senior Research Fellow based in India where he works with Sangath and the Public Health Foundation of India . He is also the Joint Director of the Center for Global Mental Health at the London School of Hygiene & Tropical Medicine . Here he writes on the ‘global crisis’ posed by Depression and challenges the view that this disorder is merely a consequence of the ‘Americanization of mental illness’.
This year’s World Mental Health Day was focused on Depression, which the World Federation for Mental Health warned poses a ‘global crisis’. A mountain of evidence was marshaled to support their case: Depression affects more than 300 million people around the world (arguably, it is the most common of all mental disorders), it is associated with profound social and economic consequences, and, 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. The strongest critics challenge the very notion of Depression as a disorder in the first place and equate its application across cultures to psychiatric imperialism; one commentator has famously referred to the globalization of the concept of Depression as the ‘Americanization of mental illness’ . These dissenting voices argue that what some would call Depression is, in fact, a normative human response to social adversity (for example, losing someone you love or your job), and that applying a medical label wrongly converts a normal human reaction into a disorder. Worse, they argue, applying such labels furthers the pernicious agendas of the professional mental health sector and its bedfellows in the pharmaceutical industry.
What do we make of these contrasting views? Is Depression a real disorder? Does it really occur in non-Western settings? If so, how then do we distinguish the experience of the misery of daily life from a clinical disorder?
There is little doubt in my mind that Depression, particularly in its most severe instances, is a real disorder; as real as diabetes, which, like depression, occurs at the extreme end of a sliding scale 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 easily 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 practice: every system of medicine from time immemorial has described a syndrome akin to what we today refer to as Depression (albeit with different names in different places). Depression has existed as long as mankind has, 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 in distinguishing Depression as an illness from the despair of everyday life. One of the inherent difficulties in making this distinction lies in the fact that the experiences which are characteristic of Depression, for example low mood, loss of interest in one’s daily and enjoyable activities, and fatigue, may also form part of our normative response to hardship or loss. This is in contrast to many other mental disorders such as the psychoses (where the symptoms are rarely encountered in everyday life), but it is not so different from many other chronic conditions such as hypertension. After all, there is no absolute line distinguishing high from normal blood pressure.
Nevertheless, in clinical practice, research and public policy, defining a disorder is often essential. Decades of psychiatric research has worked towards defining the boundary between misery and disorder. Currently Depression is defined and diagnosed using a phenomenological approach – by looking at the phenomena of the illness, its number, type, duration and severity. This approach is not perfect, but it is the best we have, and there is work afoot to refine it.
Critics argue that there is no validity to the diagnosis of Depression (and indeed, other mental disorders) because there is no biological marker to verify the diagnosis. According to this world-view, a person is sick only if one can identify a biomarker (a biological indicator) for their sickness. By this yardstick, TB could not have been defined as a disorder until Koch discovered the bacillus which causes it.
But if we are to understand the causes of human sickness, we need to differentiate between, and consider, both the illness (the sickness as it is experienced by the individual) and the disease (the biological basis for the sickness). In order to identify the ‘disease’, one has to first define the ‘illness’. Without the latter, the former will always be elusive. So, in rejecting the phenomenological approach adopted in psychiatric diagnosis because there is no biological definition for the disorder, the critics damage our chances of ever identifying one!
Depression is a global crisis not only because it is common but because the vast majority of affected people suffer in silence due to stigma, lack of understanding and lack of access to appropriate care. Depression, at least at its severe end, is a brain disorder and we will discover, in due course, its biological mechanism. We need to move firmly beyond the hackneyed and misinformed views that Depression is a ‘psychiatric invention’ to investing more on understanding its nature, addressing the stigma around mental illness, and improving access to the treatments we already possess. These are, unsurprisingly, the Grand Challenges in Global Mental Health1.
1. Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS, et al. Grand challenges in global mental health. Nature. 2011 Jul 7;475(7354):27-30.