Is Depression Universal?

Psychiatric and medical professionals export and utilise western models of mental illness that prescribe a fixed set of symptoms which correlate to form what is termed ‘depression’. According to the DSM-IV-TR criteria for Major Depressive Disorder (MDD), depression is described as ‘depressed mood or a loss of interest or pleasure in the daily activities for more than two weeks’ (2000: 356) as well as impaired social, occupational and educational function, followed by 9 symptoms, 5 of which have to be present for someone to be diagnosed as ‘depressed’. This model assumes that depression can be applied universally across cultures, despite cultural variation. In response to this, several anthropologists have argued that depression as a disorder is a Western cultural construction that mobilises western biases of mental illness, personhood, self and suffering, amongst others, while simultaneously ignoring depressive symptoms that fall outside its parameters (Kleinman 1977: 3). They maintain that the meanings and significance of these expressions may differ substantially across cultures (Tsai and Chentsova-Dutton 2010: 468). These anthropological analyses view depression as a mood, rather than a syndrome. In this essay I will analyse the biomedical approach to depression, which assumes a universal description, juxtaposed with the ethnographic model used by anthropologists, which argues for depression’s relativity. The debate on the universality of depression prompts us to re-evaluate the ways in which culture effects the diagnosis and symptoms of mental illness and to what extent western biomedical models should, and can be exported cross-culturally.

The biomedical approach contends that depression is universal by assuming that despite the cultural context, the disorder exists if members report having the symptoms associated with it (Tsai and Chentsova-Dutton 2010: 468). This model relies on survey data and data from structured diagnostic interviews to illustrate cross-cultural frequency rates of depression (Tsai and Chentsova-Dutton 2010: 468). It draws on notions of universality similar to that proposed by Darwin, where in Expressions of the Emotions in Man and Animals, he hypothesised emotions and feelings to be ubiquitous amongst all humans, despite cultural, social and racial variation. We can therefore see this biomedical approach to mental illness as part of an attempt to provide a universal framework for human suffering. In doing so, it assumes that the feelings of loss, hopelessness and emptiness associated with the western model of depression are perceived as deviant or abnormal states of being cross-culturally.

Assuming such universality has been critiqued as ethnocentric, where western cultural categories mobilised through psychiatric theories of mental illness are imposed on other cultures as though their own classifications of illness were culture-free (Kleinman 1977: 4). In positioning western cultural categories that shape the diagnosis and definition of depression as neutral and normative, the biomedical model does not take into account that, as Kleinman reiterates, ‘illness is by definition a cultural construct’ (1977: 9). Instead, this model deems culture to be both secondary and separate from the disorder (Tsai and Chentsova-Dutton 2010: 470-71). Consequently, when this model is implemented in non-western cultures and in diasporic ethnic minority groups, the ‘illness’ aspect of mental illness, which is shaped by human experience, culture and understandings of the self, is effectively ignored. In addition to this, biomedical models of depression, as mentioned earlier, usually rely on survey and interview data. The data taken from these studies do not take into account the different perceptions of mental illness across cultures, which may effect the resulting data variation. Negligence to take this into account therefore impedes the accuracy and value of the resulting data when evaluating depression cross-culturally.

On the other hand, the relativist argument, which has been adopted by many anthropologists who have taken an ethnographic approach to understanding mental illness, conjectures that even if individuals of a particular culture experience the symptoms classified by western psychiatrists as ‘depression’, the meanings and significance of these expressions may differ substantially across cultures (Tsai and Chentsova-Dutton 2010: 468). The argument against the universalism of depression emphasises that while feelings of loss, hopelessness and emptiness may be universal, the structures, norms and values that determine the meaning of these feelings vary cross-culturally. Moreover, anthropological works also suggest that the westernised presentations and conceptualisations of mental illness that are exported to non-western countries are largely only effective as medical models on western populations. This is due to not only theoretical models of depression being cultural constructions, but to the term ‘depression’ itself being a product of western culture. Kleinman has termed this overlay of western cultural categories as the normative ideal on other cultures a ‘category fallacy’ (1977: 4). He argues that, in order to overcome the issue of creating a category fallacy in cross-cultural psychology, one must systematically analyse and compare the relevant illness categories before studying the illness (1977: 4).

Moreover, anthropologists also assert that current models of depression are based on western perceptions of human nature, the self, the body and the mind. In Crazy Like Us: The Globalisation of the Western Mind, Watters argues that the advancement of western notions of mental health imposes western beliefs about human beings, deviance, and what types of life event may trigger psychological traumatisation (2011: 4). For instance, in the West, depression and other forms of mental illness are often characterised as deriving from either mental or biological interferences. This is particularly reflected in the way depressive disorders are treated. Recent shifts in treatment patterns for instance, have resulted in the popularisation of neurobiological treatments such as the prescription of anti-depressants, over psychological remedies such as talk therapy. Many non-western cultures however, do not identify with the Cartesian dualism that separates the body from the mind (Scheper-Hughes and Lock 1987: 6). Instead, Tsai and Chentsova-Dutton maintain that many non-western cultures believe that the body and mind are integrated, which may explain why some symptoms exhibited by non-western people are excluded in the DSM diagnostic specifications (2010: 475). For example, many non-western cultural groups such as the Chinese often exhibit somatic symptoms of depression, which relates to the belief of mind-body integration (Kleinman 1977: 5). This is also indicated in many indigenous treatment methods such as acupuncture and yoga, both of which treat the body and mind together. This cross-cultural variation in the phenomenology of depression is evidenced in Kleinman’s psychiatric studies amongst Chinese patients in Taiwan. He found that a substantial number of his patients reported somatic complaints, and 40% of those who somaticised their illness believed their physical sickness to be the problem, rather than having a psychological basis (1977: 5).

Diagnosis of depression is also based on western ideas of the self and personhood. This is reflected in western models of mental illness, where depression is described as an individual, internal state. Lewis-Fernandez and Kleinman elaborate on this by arguing that in relation to notions of personhood, autonomy is very important in western culture, and so the concept of personal control is closely linked to both the definition and diagnosis of depression (1994). Defining depression as a bound, individualised and internal illness is relative to western culture, but does not apply to non-western cultures that function on collectivist, rather than individualist, ideas of the self. Diagnosis of depression does not take into account the conceptualisation of the self in collectivist societies, where shared inter-subjective emotions may influence depression in people through defective relationships and other social sources.

In addition to this, anthropologists have argued that biomedicine has endeavoured to impose rational, Eurocentric frameworks on modes of suffering (like depression). Not only is the institutionalisation of suffering dehumanising, but it also portrays suffering as something unnatural and treatable. Obeyesekere, in his paper on depression and Buddhism, argues that some cultural groups normalise and naturalise suffering (and as a result, depression) (1985: 135). Through analysing the ways in which depression in Sri Lanka is not free-floating like it is in the west, but tied to the ideology and culture of Buddhism, he argues that suffering for many Sri Lankans is seen as the natural product of the shifts in life (1985: 135). In such a context where suffering is naturalised and being ‘depressed’ is not seen as an abnormal state of being, western models of depressive disorder are to a large extent inapplicable.

One criticism of ethnographic models of relativity however, is that since ethnographies tend to be in-depth and personal, they do not usually include large sample sizes. For instance, Kleinman’s study amongst Chinese patients in Taiwan only used a 25 patient sample size, which limits the generalisability of the research findings. The degree of influence of a researcher’s cultural bias on their observations is also questionable (Tsai and Chentsova-Dutton 2010: 470). Moreover, many of these studies are not conducted comparatively, which brings into question whether the meaning and consequences of depressive symptoms differ cross-culturally as extremely as ethnographic accounts suggest (Tsai and Chentsova-Dutton 2010: 470).

By comparing the western biomedical model that argues for depression’s universality and the ethnographic model used by anthropologists to argue for its relativity, it is clear that illness is itself a cultural construct. Depression is therefore relative to its cultural context, where its affects are given cultural meaning and significance. Consequently, anthropological understandings of the ways in which cultural experience effects the meaning and consequence of symptoms are integral to our conceptualisation and understanding of mental illness.

Short academic paper written in May 2014 for Anthropology of Health class