Dan G. Blazer - The Age of Melancholy: Major Depression and its Social Origin

A few years ago, I worked with a group of valued colleagues to sketch a geriatric psychiatry research agenda for the future. We agreed that a focus on major depression made sense as a starting point. The umbrella term major depression encompasses quite a few types of inquiry. We added many research projects to the agenda, including brain imaging of severely depressed older adults and clinical trials of new, promising medications. I am a social epidemiologist and a geriatric psychiatrist. I also am a little older than these colleagues and well remember the heyday of social psychiatry in the United States. It seemed obvious for me to add items to the agenda from my research and clinical experience.

I suggested that we add the study of primary prevention for late-life depression to the agenda. The social stressors of late-life, such as the lack of economic resources or the fear of crime, seemed obvious topics to study. In other words, I proposed that we research ways in which depression can be prevented in the first place. My colleagues turned to me in disbelief. One responded, There is no primary prevention of major depression. I stared back in equal disbelief. Of course, no one had yet proved that changing the living conditions or the social context of an older adult would prevent late-life depression. But we were setting a research agenda for the future, not summarizing findings from the past. Could my colleagues believe that such an intervention was not even feasible? Could they totally discount the context of late-life depression and refuse to add explorations of the social origins of depression to the agenda? Yes, they could! I realized, to my dismay, that social psychiatry had all but disappeared from the view of most psychiatrists.

Social psychiatry, which thrived during the 1960s, is virtually moribund in the United States, whereas major depression, born during the late 1970s, has become an everyday label accepted by psychiatrists, their patients, and the public. The term major depression could scarcely be found in the psychiatric literature prior to the publication of the research diagnostic criteria in 1978 and their expansion in the third edition of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental DisordersThird Edition ( DSMIII ) in 1980. I believe the advance of major depression as a diagnosis and the retreat of social psychiatry are linked.

During the 1960s, clinically significant depression was divided into two categories: reactive and endogenous (or internal). The most common form of depression was diagnosed as depressive neurosis (a reaction). In contrast to the more severe endogenous depressions, such as manic-depressive illness, the much more frequent depressive neurosis was caused by an excessive reaction to internal (psychodynamic) and external stressors. An external stressor was essential to the onset of reactive depression, whether that stressor was the loss of a loved one or a response to a dysfunctional social environment. Depression was a complex malady that required a comprehensive explanation.

In the past, psychiatrists expended many words describing the emotional suffering of their patients, for no one word conveyed from one psychiatrist to another the nature, context, and severity of the suffering. The advent of the new diagnostic system allowed psychiatrists to use one label, such as major depression , and another psychiatrist knew what the first had observed. The new nomenclature says, essentially, that a person has major depression if the following criteria are met, such as a depressed mood and five additional symptoms lasting at least two weeks. Therefore, psychiatrists have become more reliablethat is, consistentin their use of terms.

Unfortunately, though, much of the richness and context of the more lengthy discussions of the past have been lost. Psychiatrists, it seems, have come to believe that if they label the person with a diagnosis such as major depression, they have said it all. In other words, there is a real disease called major depression and, by attaching the label, the psychiatrist pronounces that the patient has this disease. (This process of making an idea real has been labeled reification. To treat an abstraction as substantially existing is to reify the abstraction.) Reification numbs us to the possibility that depression can be more a signal of the emotionally toxic society in which we live than a thing in and of itself. And if the effects of this toxicity are initially expressed through depression, then depression should signal a need to better understand and improve society.

During the first 60 years of the 20th century, medicine in general and psychiatry in particular became increasingly concerned about social and cultural contributions to illness onset. There was widespread interest in the potential of community-wide interventions that might decrease the onset and persistence of those illnesses. Social medicine arose from general medicine as a separate entity, even a specialty (though never a large one). The research arm of social medicine was epidemiology, with a specific emphasis on social epidemiology. Departments of social medicine were almost always separate from departments of internal medicine and were more aligned to schools of public health.