Teorías y lecturas sobre la expansión del islam saheliano

In the contemporary world depression is generally considered a major health problem (Mann 2005, Andrews 2001, Glass 2003) and accounts for one third of primary care consultations (Gilbody et al. 2003: 3145). In Australia, depression is the most common mental health disorder (Vos et al. 2005). However, depression, as it is understood today, would have been an alien definition half a century ago when diagnoses of depression were rare (Healy 1997). As a medical label, depression is a creation of Western twentieth century psychiatry and is “historically and culturally located in very recent times” (McPherson & Armstrong 2006: 57). Ongoing efforts, in both medical and sociological research, to adequately define the problem of depression have produced a plethora of cogent possibilities, often in varying degrees of disagreement. Indeed, to appropriate Pilgrim and Roger’s description of mental health and illness (1999: 11), depression is a “highly contested” problem.

This lack of consensus is indicative of two interrelated factors: the plurality Weber saw characterizing the modern secular world still operating under the auspices of a total world-view and the Western rationalism Weber saw determining how the world was approached and understood. The positive result of this is that there is a variety of opinion, but the negative result is that the differences of opinion are usually considered to stem from misinterpretation of data or not understanding the problem of depression. The latter tend to overshadow the former. The value of the interpretative orientations in my theoretical model is that they demonstrate the framing of the problem rather than becoming entangled in the disagreements between various attempts to define and solve the problem of depression. Despite the lack of homogenous opinion, defining the problem of depression is largely founded on diagnostic concerns. In both medicine and sociology, ways of determining and measuring depression is central to how the problem of depression is defined.

In medicine, depression is considered to affect both mind and body (Insel & Charney 2003) and the diagnostic criteria reflect this approach. However, although this approach is at least partly holistic depression is generally seen as a malfunction of brain circuitry and / or chemical interaction (Davidson et al. 2002, Ebmeier et al.

2006). While there has been a continual interest by psychiatry in biology (Moncrieff & Crawford 2001), it was DSM-III, marking the supremacy of biological over psychoanalytical psychiatry and resulting in an emphasis in diagnosis of depression firmly based in biology, that had a significant impact on how patients were subsequently diagnosed (McPherson & Armstrong 2006). Between DSM-III and

DSM-IV, there was a broadening of diagnostic criteria and a proliferation of sub- categories of depression, which is often cited as the reason for increased diagnosis of depression (Ebmeier et al. 2006, Horwitz & Wakefield 2007, Karp 2007) as well as diagnostic confusion (Parker 2007, 2008a) and disagreements over the production of a valid classification system (Joyce 2008).

Defining depression in a restricted scientific manner reflects its origins in a rational framework, even though there is an awareness of a wider perspective. Social and demographic variables (such as poverty, unemployment, stress), while acknowledged by the DSM-IV in Axis IV, for example, are subsequently excluded from criteria used to make a diagnosis (Horwitz & Wakefield 2007). This effectively removes such variables from how depression is defined because the “psychosocial and environmental problems” are separated from diagnostic criteria even though they are recognized as having an impact on diagnosis and treatment (Horwitz & Wakefield 2007: 114). The DSM approach contradicts the findings of France and colleagues (2004: 228) who found that depression is part of a “multifactorial cluster of negative conditions” that include marginal social status, and of other medical opinion (Heath 2005) that suspects the prescribing of antidepressants when poverty and inadequate housing are the real problems is not uncommon among general practitioners.

Nevertheless, medicine in Western culture decides what constitutes disease through its diagnostic systems of labelling. In Levinasian terms, diagnostic labelling as a process of defining problems translates the faces of Other (the diseases and illnesses) into Same (diagnostic categories of diseases and illnesses) so that in the naming process they may be defined and controlled. “Diagnosis is a thoroughly semiotic activity, an analysis of one symbol system followed by translation into another” (Kleinman 1988: 16). This process of imposing order on the world from a particular perspective, of essentially constructing a reality, constitutes “‘a major dimension of political power’” (McGuire 1990: 290, quoting Bourdieu).

The development of psychiatric labels to define depression and serve as the basis of diagnosis is related to professional development and to the emphasis in Western rationality on evidence-based description. McPherson and Armstrong (2006: 58) suggest a link between the development and maintenance of psychiatry as a profession and the need to establish consistent diagnostic criteria (such as depression), arguing that “control over the diagnostic labelling process was vital” in the creation of “a dominant power base for itself as a profession”. This labelling process, reflecting the eventual dominance of biological understandings of depression, is firmly structured on a scientific foundation. The labelling process continues in the creation of new sub-categories of depression (Ebmeier et al. 2006) and of labels for other emotional states such as ‘social anxiety disorder’ (Schneier 2006), ‘panic disorder’ (Katon 2006), and ‘social phobia disorder’ (S. Scott 2006). The recent publication of a number of books (Horwitz 2009) about the complex relationship between consumer culture, the marketing of psychiatric drugs, and the profession of psychiatry (Herzberg 2009, Shorter 2009), which both reflect and drive the search for therapies to treat emotional stress and suffering, indicates such discussions are likely to continue.

Concerns that human emotions have been disembodied, with dysthymic states now routinely diagnosed as mental illness (Williams 2000b), and that normal sadness is now diagnosed as depression (Horwitz & Wakefield 2005, 2007) directly reflect Weber’s concern over the problems inherent in scientific rationality being employed beyond its parameters. This is also reflected in research (Thomas-MacLean & Stoppard 2004: 287-288) finding a “disjuncture” between medical training about depression and doctors’ experiences of the social aspects of depression because the “scientific ideology” of the medical model of depression “fails to address the complex nature of depression”.

Central to the diagnosis of depression is the role of the health professional. Emphasis is often placed, due to poor professional-lay agreement in assessing depressive symptoms, on the expert role of clinicians over members of the public (Parker et al. 2003). Other opinion, however, emphasizes the salient nature of patient and family experiences of depression (Highet et al. 2004) and the unacceptability of dismissing lay input and the importance of professional-lay partnerships (McGrath 2002). Such

disparate opinions clearly reflect the tensions in the historical orientations concerned with the place of the elite and laity that impact on approaches to health and illness. However, a focus on patient and family can inadvertently reinforce the reductionist model (Freund & McGuire 1995) or “‘individualist model’” (McClean 2005: 644, quoting Donahue & McGuire) of medicine, as opposed to the social, easily translating into an equation of individual responsibility and recovery. Petersen and Lupton (1996: 118) argue “that more and more ‘environmental’ risks are now conceptualised as amendable to personal control”. All positions reflect, nevertheless, a focus on the need to define depression as a problem so that it can be solved.

Within psychiatry, much emphasis and credibility are attached to correct diagnosis, with clinical criteria usually drawn from the standards set by professional bodies (Mann 2005). The Diagnostic and Statistical Manual of Mental Disorders (currently

DSM-IV), produced by the American Psychiatric Association, and the International Classification of Disease (currently ICD-10), produced by the World Health Organization, are the dominant diagnostic systems worldwide. While the DSM-IV is highly influential and is “the most widely used classification system in Australasia” (Ellis et al. 2004a: 892), Parker (2007: 328) considers the increase in diagnosed depression partly due to the “lack of a reliable diagnostic model”. Nevertheless, based on these guidelines, depression is considered to be “qualitatively different” from transient low moods (Ellis et al. 2004b: 389). As a diagnostic term, depression is used for describing “a spectrum of mood disturbances … [that] are judged to be of clinical significance when they interfere with normal activities and persist for at least two weeks” (Peveler et al. 2002: 149). Depression is also considered to be a “chronic and recurrent illness” (Keller 2003: 3152) or a “relapsing condition” (Ellis & Smith, 2002: S81), displaying “a high rate of recurrence” (Ellis et al. 2004b: 389).

Related to the emphasis on diagnosis is concern with remission and how it is to be defined. In viewing depression as a problem to be resisted, remission from depression is seen not merely as the ideal endpoint, but the only endpoint. Importantly, because medical opinion considers remission to be the optimal treatment outcome, the importance of how remission is indicated impacts on the systems of diagnosis and assessment (Keller 2003). Although recurrence rates are high, there are few strong predicators of remission (Eaton et al. 2008). The

underlying emphasis in opinions and criteria concerning depression diagnosis and remission is one of resistance; a resistance based on scientific evidence directed at clearly defining the problem of depression in order that this problem can then be effectively solved.

There is debate about depression as a category, however, when it is clearly part of a continuum of mood:

Despite awareness of the continuity between normal sadness and clinical depression, the diagnosis assumes that clinical depression exists as a category (rather than on a continuum). It is unclear, however, who decides where the cut-off mark is, and on what basis. (Timimi 2004: 1395)

Commenting on this issue, Kleinman (2004) considers that some of the uncertainty with diagnosis of depression is due to problems associated with the use of the DSM- IV and the way that illness is demarcated from ‘normal’. For example, the DSM

defines a person as depressively ill if their bereavement grief lasts longer than two months, when it may be considered by others to be “a sign of the moral experience of suffering” (Kleinman 2004: 952). Further, this bereavement clause only includes the death of loved ones and not other major losses for which depression may be considered a normal reaction (Horwitz & Wakefield 2005, 2007, Wakefield et al. 2007). There is also considerable diagnostic fuzziness, and associated disagreement, about the dividing line separating other psychiatric conditions, such as anxiety, from depression (Pilgrim & Bentall 1999) and different opinions regarding the diagnostic co-morbidity of depression and anxiety (Moffitt et al. 2007).

A strong emphasis on evidence, nevertheless, prevails in the production of psychiatric depression guidelines. In 2004, the Royal Australian and New Zealand College of Psychiatrists produced a set of guidelines for the treatment of depression that relate to both the DSM-IV and the ICD-10 (Ellis et al. 2004b). While this paper was strongly criticized from within the profession (Parker 2004a), it is argued by the primary authors of the guidelines (Ellis et al. 2004a) that it is evidence-based and makes sound recommendations for the treatment of depression that are in agreement with similar guidelines from the United Kingdom and the United States. The authors of these guidelines admit that their approach “may lack intellectual rigour, but when

some of the best minds in psychiatry cannot agree on the most appropriate classification, a pragmatic approach is required” (Ellis et al. 2004a: 892). Such a statement is an honest recognition and assessment of the highly contested area of how to define and diagnose depression, which stands in contrast to those of Rubinow (2006) and Parker (2004a) who consider diagnosis simply reflective of correct scientific approach and classification.

Parker (2004b) is concerned that clinical guidelines should be practical and involve common sense as much as science and theory, but his emphasis and approach are, nevertheless, heavily weighted towards the scientific basis of the medical paradigm and the use of clear diagnostic tools based on multi-dimensional modelling (Parker et al. 2008, Parker 2008b). Weighting DSM diagnostic symptoms, rather than merely counting, is also suggested as an approach that may help overcome problems with using the DSM system (Sakashita et al. 2007). It is noteworthy that attempts to rectify problems with diagnostic systems focus on re-modelling the existing approach rather than examining why this approach, a Western rationalist approach, is used in the first place and investigating the difficulties it may be causing.

The emphasis on defining depression is based on diagnosis and a major problem with diagnostic systems is their inherent classificatory approach to depression, particularly when diagnosis is concerned with emotional states for which there are no biomarkers or tests (Insel & Charney 2003, McPherson & Armstrong 2006). This situation explains the emphasis in psychiatry on the future research potential of areas such as genetics (Bennett 2007) and neuroscience (Davidson et al. 2002). There is, however, an attendant problem in using specified criteria for diagnoses: when the criteria changes so do the diagnoses. One reason for the increase in rates of depression could be linked to changes in the DSM criteria. The “early versions … drew the boundaries of depression much narrower than DSM III or IV” (Ebmeier et al. 2006: 153). Defining depression according to scientifically based classificatory systems is problematic (Summerfield 2006a). It can lead to the pathologizing of the human condition, resulting in labels of illness for what in previous centuries in the West were taken to be ordinary aspects, however difficult and painful, of life and living (Shaw & Woodward 2004b, Horwitz & Wakefield 2007, Karp 1996, 2007). Despite concerns about the impact of changing diagnostic guidelines on depression diagnosis

rates (Parker 2007), there is still widespread opinion that depression remains seriously undiagnosed (Peveler et al. 2002), perhaps by as much as up to fifty percent in primary health care (Henkel et al. 2003).

Nevertheless, the universal relevance of diagnostic tools is challenged in both medicine and sociology. Is depression, as classified in diagnostic systems, “always a timeless, free-standing, coherent, universally valid, pathological entity with a life of its own?” (Summerfield 2006b: 1235). For example, different cultural backgrounds can complicate diagnosis and treatment of depression (Kleinman 2004), with diagnostic systems requiring modification when translated into different languages to make them culturally relevant (Patel et al. 2001). Studies of other cultures reveal that the way depression is defined in the West as a health problem that is reducible to diagnostic criteria is culturally constructed (Coker 2003, Skultans 2003, Wight et al.

2005). The emphasis on the individual patient in the diagnosis and treatment of depression that characterizes the Western approach to depression contrasts with other cultures that see depression as socially based (Karasz 2005, Lackey 2008).

Issues of gender (Nazroo et al. 1998, Bracke 2005, Väänänen et al. 2008) and socio- economic position (Meertens et al. 2003, Zimmerman et al. 2004) also challenge the neutrality and validity of diagnostic guidelines. There has been criticism of diagnostic categories displaying unintended gender preference with a need for gender-neutral diagnostic guidelines containing “gender-sensitive instruments that are more likely to pick up the symptoms of depression in men” (Brownhill et al.

2005: 929), and for an integrated model that can solve the puzzle of gender differences in depression (Hyde et al. 2008). Other interesting research has revealed that depression predominates as a diagnosis in the middle class whereas schizophrenia predominates in the lower class, and that the middle class suffer from mental illness whereas the lower class inflict suffering on the public because of their mental illness (Olstead 2002).

The way in which diagnostic guidelines fail to allow for the relationship between social factors and depression, and how these can change over time, was demonstrated in a recent Dutch study (Meertens et al. 2003: 208) that found between 1975 and 1996 divorced people “became progressively less likely to suffer from depressive

symptoms” as divorce became more socially acceptable. In addition, age has been raised as a factor that current diagnostic guidelines do not adequately cater for. Two- thirds of older people suffering from “serious depression do not have symptoms that fit current classifications of mood disorders, which have been generated to reflect symptoms in younger people” (Chew-Graham et al. 2004: 181). There is also concern regarding the diagnosis of depression in children and adolescents (Timimi 2004), despite other concerns that half of adolescent depression is under diagnosed (Ryan 2005). A combination of diagnostic guidelines and clinical expertise in which there is a “careful balance between prudence and validity” is suggested as the optimum approach for dealing with the short-comings of diagnostic guidelines in day-to-day medical practice (Nease & Aikens 2003: 1031).

There are difficulties inherent in a diagnostic approach to depression that is centred on resistance to depression. One of the disadvantages of this resistance approach to depression is that viewing it as a problem to be defined can obfuscate awareness that depression has been labelled as a problem in the first place. There is also a danger that sociology can inadvertently perpetuate dualisms of mind / body and emotion / reason by following medicine in equating unhappiness with mental illness and happiness with mental health (Williams 2000b), even though a sociological perspective is used in which the medical perspective is criticized. Sociological research can be both critical and supportive of the medical position at the same time: supportive of the wider framing (i.e., Western rationalism or a Rousseauistic Interpretation) and critical of the specifics of the medical interpretation of the problem. For example, the controversial nature of some psychiatric diagnoses reflect difficulties with psychiatric diagnosis generally (Manning 2000), but they also reflect origins in a certain way of understanding the world from which such interpretative orientations have their genesis. Similarly, discussions of the role that sociology can play in the area of symptom recognition in mental illness (Palmer 2001) actually aligns such sociological research directly with medicine even as, through its criticisms, it diverges from medicine. There is a danger that sociology risks not only inadequately addressing failings in psychiatry (Horwitz & Wakefield 2007) but also perpetuating and reinforcing society’s paradigms of health and illness (Radley 1999). Nevertheless, sociological research explicating social dimensions is revealing of important information about how depression is defined in the social realm.

Defining the problem of depression, then, results in a variety of approaches and emphases in both medicine and sociology concerned with resisting depression. While there is consensus regarding the need to define the problem of depression there is no consensus regarding what this definition should be. The resulting contestations and confusions over defining depression make it seem “‘at once familiar and mysterious’” (Pilgrim & Bentall 1999: 265, quoting Seligman). Examining the differing approaches to depression reveal the interpretative orientations to be firmly grounded in a scientifically rationalist world-view. Such a view is centred, in Weberian terms, in Western rationalism, or, in Derridean terms, in a Rousseauistic interpretative position. Resisting depression through defining it as a problem also reflects the intent, in Levinasian terms, to control the face of the Other by defining and labelling it. This is why an approach in which the interpretations are interpreted helps elucidate the why behind the interpretative what.

While diagnostic criteria and classifications “remain controversial” (Ellis et al.

2004a: 892), their essential characteristic is concerned with defining the problem of depression. The existence of differing interpretations is positive, as it contributes to ongoing refining and expanding of ideas in both sociology and medicine. However, the belief in a total world-view has bequeathed a sense that there is a right way of defining the problem of depression. This often overshadows the values inherent in these various interpretative orientations and tends to draw discussions into disagreements about aspects of these interpretative orientations rather than the form that they take. Similarly, solving the problem of depression also produces equally differing and contested approaches enmeshed in disagreement about details.