Posted on February 9, 2010 - by David
Allan Horwitz on the Medicalization of Depression
A few weeks ago a friend of mine sent me a link to a podcast interview with sociologist Allan Horwitz, author of a book called The Loss of Sadness which looks at the medicalization of depression. If you’re going to listen to the podcast, skip ahead to 4:51, where the interview (which lasts about 20 minutes) actually begins.
at 6:50 into the podcast, Horwitz says:
… In the current environment, genetic explanations are, one, given tremendous credibility, so if you can link things to genes that somehow makes it more important explanation than linking them to life histories or linking them to social circumstances… and that’s a cultural phenomenon, [there’s] no reality that they’re more important… And the second important phenomenon, which I also think is purely social, is that if phenomena are linked to gene it makes them seem as if they’re disorders whereas in fact there’s genes for perfectly normal personality dispositions or there’s probably genes that make us grieve when somebody close to us dies, certainly doesn’t mean bereavement is a disorder, but that the cultural valence of genes associates them with mental disorders..
At first, I was happy to hear someone point out that the prominence of genetic explanations of mental illness is a cultural phenomenon, not a reflection that they are actually more important than other perspectives. However, I got more and more confused as I considered what Horwitz actually says in this interview. Let’s just look at the above statement piece by piece.
1. It is a cultural phenomenon that genetic explanations of mental illness are given such prominence. Ok, check, I follow.
2. Linking phenomena to genes makes it seem as if they are disorders. Ok, I think I’m still with you, but are you telling me they have succesfully linked specific genes to mental disorders?
3. There are genes for behavior which we would consider normal, such as expressing grief when someone close to us dies. Wait, so are you saying there’s a gene for everything I do? Have they even linked sarcasm in blog posts to genes?
Let’s look at another piece of the interview, at 12:36
Horwitz: Depression is probably one of the very few psychiatric illnesses that’s been recognized for thousands of years, so it’s certainly not something that’s a new condition. From the ancient Greek philosophers, through the renaissance period, through the early psychiatrists, even through Sigmund Freud and the DSM I and the DSM II – it had always been a contextualized illness so that the people who become sad or even intensely sad in contexts where we would expect people to be sad – the loss of intimates, diagnoses of a serious physical condition, serious economic difficulties- these sorts of things were always clearly distinguished from the mental illness of depression, which either arises with no context or persists longer than the original context in which it arose or features extremely severe symptoms- vegetative symptoms, hallucinations and delusions, these sorts of things.
Interviewer: So you’re saying that there’s been this historical legacy of seeing depression as a pathology only when it doesn’t fit the context, when it doesn’t fit the situation.
Horwitz: Precisely, the symptoms are identical but one is contextually appropriate and the other is without cause or without reason.
Now I guess I’ll have to read his book to see if he gives evidence for his claim that depression has been recognized for thousands of years and has “always been clearly distinguished” from normal, “contextually appropriate” sadness. (I will point out that all the examples he rattles off are clearly part of Western culture). It’s a bit confusing that he says the symptoms of “the mental illness of depression” are more severe than expressions of normal sadness, and then later says “the symptoms are identical” but in some cases they are not contextually appropriate. I do get the point he is trying to argue- that social and other contexts should be taken into consideration when making a diagnosis of depression- but I’m don’t think he’s being very clear or convincing.
He is critical of the emphasis on genetic explanations of mental illness because it confuses normal reactions to life with disorders, but at the same time he claims that the “the mental illness of depression,” where the symptoms are severe and not contextually appropriate, has been recognized for thousands of years. So his argument basically amounts to a claim that the prevalence of depression is greatly overestimated because context is no longer considered when diagnoses are made. But where does this leave us with regards to the real, true cases of depression? Apparently, context can help explain why some reactions aren’t disorders, but Horwitz says nothing about how cultural context can account for the phenomena which actually are disorders. In fact, Horwitz seems to inadvertently reaffirm the prominence of the biomedical/genetic account of mental illness. By essentially suggesting that phenomena which can be explained by social and cultural contexts are not actually disorders, he places the true, severe, undeniable forms of mental illness in a category which only biology and medicine can touch.
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February 17, 2010
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Arturo said:
I’m glad you liked our podcast and/or found it interesting enough to write about. If you think Horwtiz is a biological reductionist, you should listen to our first episode on this genetics series where we interview Thomas Bouchard, who has done alot of work with twins. That’s a real reductionist, though he has some interesting points.
http://contexts.org/podcast/2009/11/17/genes-behavior-and-science/
I think you’re right that Horwitz came off a little unclear at times in the interview, but you should understand that he wasn’t really given a chance to prepare–I kind of track down these guests and turn on the recorder. But I do like how Horwitz frames his critiques aganist the narratives of genetics. The prevailing logic at the NIMH these days is that everything is influenced by genes (this is after all the “decade of the gene” according to the director) and taking this argument broadly it is hard to deny that this is true. There is rarely a single gene for a set of behaviors, but combinations of genes and their complex interactions with the environment likely “influence” at some level all the things that we recongise as “mental health” problems, or really anything. That is, genes, like blood sugar levels, or any biological process has some influence on everything we do, even if that influence is minimal or less important than the context. Instead of denying this, Horwitz is saying “fine, but so what, understanding the genetic influence of something doesn’t make it pathological.” While we may spend millions trying to find the exact combination of genes that are associated with depression, any potential findings won’t make depression any more “pathological” or “truer.” I think Horwitz is trying to point out how genetic research as a cultural product belies that we may live in a soceity where these things are more recongized as abnormal or undesirable than in the past, in addition to the fact that we may live in a society where the social conditions that evoke such feelings are more common.
But I do think you make interesting point in the end about the role of context in “real depression.” If real depression is the result of a mismatch between how we feel and context, then should mental health interventions only focus on supposed “biomedical causes” and not concern itself with the context or what’s going on in the environment. Good point, I don’t know what Horwitz would say to that. I wish I had thought about that during the interview.
This looks like an interesting blog, I will make sure to continue checking it out.
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February 17, 2010
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David said:
Thanks for the comment Arturo, I’m glad you found the site. I’ll be sure to check out that first episode you mention.
I wouldn’t say Horwitz is a biological reductionist, I think I was maybe a little hard on him just to point out how his argument could still be construed that way. I absolutely agree with his critique of the genetic approach, and feel it is important to point out (as he does) that the prominence of these apparently scientific explanations is a cultural phenomenon, not a position that has been earned by actually providing us with knowledge and understanding about mental illness. And he’s right in saying (in your paraphrased words) “so what, understanding the genetic influence of something doesn’t make it pathological.” That being said, I think his stance on the medicalization of depression makes things sound a little too black and white. Listening to him, it sounds like there are normal reactions to difficult life events and then there is this inexplicable, deep, destructive depression, with very little gray area between. Do I think the fact that depression and other, maybe milder forms of psychological suffering are opportunities for certain groups to make huge money has had an impact on the apparently high rates of mental illness? Absolutely. But the market wasn’t created out of thin air. I tend to think of mental illness as a continuum, with persistent but tolerable anxiety and malaise on one end and severe psychosis on the other, with every imaginable combination of symptoms and experiences in between, probably manifested differently even within one individual mind throughout a lifetime. I think Horwitz is right to criticize the rather arbitrary disease categories. Making a particular diagnosis often amounts to a decision about which group of drugs to try, and even here, the drugs used to treat various mental illnesses often overlap. I agree that for many people, taking a pill is probably not the answer. But I wouldn’t say that what is happening in the minds of Americans and other citizens of the modern world is necessarily “normal.” I believe there is something very wrong, I just don’t believe it can be explained by some genetically caused “chemical imbalance.” The message I get from Horwitz is that most people we have labeled as “depressed” are experiencing normal human emotions that people in the past were able to deal with, and we should deal too. However, I don’t believe that what we experience today is the same as what the ancient Greeks experienced. The very nature of what we consider a difficult life event has changed. Losing your job, being passed over for a promotion, going through a divorce, being rejected from your first choice of college, losing money in the stock market (while still retaining plenty of resources to cover all your basic needs) – these stressful situations (all of which relate to issues of individual identity) didn’t really exist a thousand years ago. Not only do the cultural messages being sent make these situations difficult almost to the point of trauma, but the structure of modern culture no longer provides people with the resources to cope. Now, in the midst of the genetically dominated, pharmaceutically driven discussion about mental illness, try to suggest that problems with identity caused by modern culture lead to a biologically real, serious depression (let alone schizophrenia) and you might just be laughed out of the lecture hall by neuroscientists and anthropologists alike. Nevertheless, that’s what Liah Greenfeld is suggesting, and to me, it makes sense.
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February 18, 2010
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Arturo said:
That’s an interesting perspective and I think you’re right about the “modern condition” perhaps being the cause of much emotional turmoil. In fact I think this is really the implicit question of most sociology–how is modern life eroding our emotional health and sense of being. From Durkheim, to Simmel to Giddens and countless others, this seems to be the underlying concern of much sociological angst. I can’t say I’m familiar with Greenfeld’s work, but perhaps it comes from this same perspective.
What I can tell is that contemporary versions of these debates draw on the loss of authenticity, community and tradition to frame the crises of identity that seem to permeate much of contemporary talk and culture. The empty-consumerism of modern practices, the ambiguous purpose of our work/life and overall post-modern malaise engender conditions where people perpetually question themselves and their lives. I wonder though if things are really much worse than they were before. You mention the loss of jobs, being passed over for promotions, and not getting into the college of your choice as current struggles that many Americans must face. While difficult, I can’t help but think that perpetual famine, war and death that dominated much of human history were far worse. If disease and starvation didn’t get you, I’m sure the anxiety of being pillaged or attacked were never faraway thoughts for most humans during the last 2 thousand years. This may be overstating it a bit, but I do think our living conditions are much better than they were in the past. Perhaps one’s sense of purpose was much clearer back then (I must survive) that when such events occurred people were better able to handle them. Perhaps it is the luxury to spend time thinking about life instead of constantly trying to survive that makes things complicated and difficult to comprehend.
Maybe I’m overly optimistic, but I don’t think the complexities of modern life are our downfall, but rather are necessary ruptures of critical thought that need to happen. It is good to question things, be critical and perhaps revamp institutions, even if these things do make us feel empty and unsure at times. There are no easy answers out there, but perhaps there never were, we just didn’t have the time to think about them. A prison guard during the Spanish Inquisition, or a colonial merchant selling goods in the Americas, probably rarely thought to themselves: what am I doing with my life, who am I, what is this system that I’m perpetuating. People certainly did have moral dilemmas but perhaps such questions never got to the core of peoples’ sense of self like they do today (or really in the last 100 years). You are probably more well read in this area than I am, but I do feel the modernity argument about mental health while clearly on to something, can be over-stated. Erich Fromm, a psychotherapist, wrote this great book in the 1950s called the Insane Society where he basically says that perhaps it is the “normally sane” person in an overly-industrialized society that is really crazy and should be studied in psychology. Sociologists in Chicago in the 1940s made a similar argument when they studied the migratory patterns of schizophrenics—they postulated that communal breakdown of urban neighborhoods created the anomic conditions that elicited schizophrenia. These arguments are persuasive in that they call attention to the lonely-reality that most people live in modern life; notions of traditional community have clearly changed. But the argument that such conditions have resulted in a mass epidemic of mental health problems have always rung a little over-stated to me. Perhaps to be “critical” and be reflective of our progress and be open to change, we have to break-away from traditional communities, or at least revision them. As a result there is great anxiety and feelings of isolation in trying to figure out what to do, and what to belong to, but maybe such angst is necessary and normal. Maybe Horwitz is right then in saying that calling such thoughts and feelings as medical diagnoses is counterproductive because fixates our attention much more on the symptoms than the conditions of these feelings.
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February 18, 2010
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David said:
Arturo
You said quite a bit, and I’ll do my best to give an adequate response…
As you say, the struggle to survive probably kept people pretty occupied, but also, religious beliefs and the idea of an eternal reward sustained far more people than today. Modern culture, being fundamentally secular, makes this life on earth ultimately meaningful, which means that we had better make the best of it, and frustrated ambition, failure, and loss become much more difficult to accept.
I certainly wouldn’t trade my comfortable modern life for one of disease and starvation. There is no doubt that in modern societies, quality of life in all quantifiable physical terms has improved immensely. My point was precisely that historically, (and in some traditional cultures today), people faced what appear on the surface to be much more difficult problems, and yet it seems they suffered less in their minds. I think it is more than just the struggle to survive that protected them. If you expect hardship, disease, and death, and you know who your family is and what social group you belong to and what activity you’re supposed to be occupied with all day long, and the possibility of changing social positions is unthinkable, then there is little room for confusion. In modern societies today, it is not just because we have all our material needs met and a lot of time on our hands that we ask ourselves, “what is this all for?”
I’ve never considered myself optimistic, but I’m certainly not saying that everything about modern culture is bad either. We have so much freedom, and a lot of good can be done with it. I agree with you that it’s good to question things and think critically – this is precisely how modern societies came into being in the first place. As Greenfeld writes, “anomie, is, in fact, the ultimate cause of cultural change. It both breaks the old cultural routine and encourages the formation of a new one.” However, she also identifies anomie as a built-in feature of modern society. Rather than quote it at length, I would encourage you to check out her essay, Nationalism and the Mind.
As far as the “normal people are the crazy ones” argument goes, don’t think for a moment that Greenfeld falls in to this category. Despite the strong likelihood that rates of mental illness are increasing, the majority of us still make it through life without a catastrophic breakdown. When asking the question, “are these people actually sick?”, it helps to consider what mental illness does to a person’s ability to function. A condition that leaves a person unable to get out of bed, work, take care of their children, communicate with others – a condition that may ultimately end in suicide – should probably be considered maladaptive.
It’s easy enough to suggest that some depressed people would do well to consider some of the thoughts and feelings that lie behind their suffering rather than just accept a medical diagnosis, but Horwitz probably wouldn’t say quite the same thing to someone (diagnosed as schizophrenic) in the middle of a psychotic episode. So what ends up happening is what I suggested in the original post – the more severe forms of mental illness are considered somehow more genetically/biologically based than milder, more commonplace conditions.
I would agree that with the present state of psychiatry, a medical diagnosis often results in fixation on symptoms. It basically amounts to saying “something is wrong with your brain.” But the existence of cognitive therapy, (and the relative failure of medication when it is not coupled with therapy), presents an interesting contradiction. The message then becomes, “there is something wrong with the chemicals in your brain, but talking and changing some of your thought patterns may help correct your brain problem.” If the problem is one of genetics or a chemical imbalance, how can culture, a symbolic process, something obviously not biological in nature, provide a solution? We are capable of changing our beliefs, of examining contradictions in societal messages, of talking through difficult memories with another human being, but I don’t think most of us are capable of altering the way our neurons fire by sheer willpower. The answer would seem to be that the interaction between culture and the brain is so intricate and delicate that it is actually capable of causing the brain to malfunction. Human beings (like all animals) need order, but ours is not written into our genes, it is provided by culture, and if culture can’t provide us with that order, bad things happen in the minds of individuals.