Intended for healthcare professionals


Depression should be managed like a chronic disease

BMJ 2006; 332 doi: (Published 27 April 2006) Cite this as: BMJ 2006;332:985

'Depression'- screening and managing what?

The recent editorial and responses to it about depression assume that
the latter has scientific validity. The concept has legitimacy in the
medical profession and amongst lay people for now, but is it valid?
Depression has certainly entered the vernacular, in Eurocentric cultures,
in the past hundred years. Diagnostic checklists from the American
Psychiatric Association's Diagnostic and Statistical Manual (DSM) and the
World Health Organization's International Classification of Diseases (ICD)
increase the probability of reliability. However, the latter is a
necessary but not sufficient condition for validity. It is also not
suprising that doctors trained with the same checklist system will agree
with one another; but about what precisely?

Grounds for doubting the validity of the diagnosis are legion (1, 2).
They include its large overlap with other categories, including anxiety,
personality disorder and adjustment disorder, as well as an inconsistent
history in psychiatric nosology about unimodal versus bimodal case
distribution, and exogenous/reactive versus endogenous claims. The latter,
causation-implied, labels are supposed to be irrelevant under DSM, which,
since 1980, has asserted aetiological neutrality, but clinicians still use
them in practice (3). Also, what of cultures which have no word for
depression, are they ignorant and mistaken about the pandemic in their
midst (4)? To insist on a global pandemic position is a form of cultural

Moreover, the current emphasis on drug treatment assumes that
depression has a self-evident and well understood biological substrate,
when it does not. To argue that 'antidepressants' rectify both serotonin
depletion and feelings of misery is like arguing that a headache is due to
a lack of aspirin in the brain. The biochemical orthodoxy about medicinal
effectiveness is undermined by evidence of the strong placebo effect in
published studies (5).

Depression is not a free standing affliction 'out there', awaiting
discovery, but a socially constructed dustbin serving the interests of
psychiatry, the drug companies and lay people who, for a range of social
and biographical reasons, experience an intensification of misery and seek
help (or have it imposed upon them). Human suffering, which comes in all
shapes and sizes, is not inherently a disease but is simply about being
alive. It is a variegated existential state, which can be shaped,
triggered, endured, resolved, avoided and escaped from in various
biographically-contingent ways(6).

Depression, like other functional psychiatric diagnoses, exemplifies
the 'epistemic fallacy'- that to name something is to make it real (7).
Confusing the map with the territory and individualising misery as a
medical condition in skin-encapsulated patients flow from a focus on this
historically-situated reification, which for now we call 'depression'.

There are three questions implied by the above doubts for for
psychiatric traditionalists, with their headlong rush into more diagnosis
and treatment. First, the pre-empirical scientific question: are we
framing the problem correctly? Second, the philosophical question: by
turning miserable people into patients, does this illuminate or obscure
the wide ranging existential dimensions to human suffering? Third, the
social policy question: can human suffering always be addressed
effectively by the technical fix of medical interventions?

(1)Pilgrim, D. and Bentall, R.P. The medicalisation of misery: a
critical realist analysis of the concept of depression. Journal of Mental
Health, 1998, 8, 3, 261—74.

(2)Dowrick, C. Beyond Depression: A New Approach to Understanding and
Management. Oxford: Oxford University Press. 2005

(3)McPherson, S. and Armstrong, D. Social determinants of diagnostic
labels in depression. Social Science and Medicine, 2006, 62, 1, 50-58.

(4) Wierzbicka A. Emotions across Languages and Cultures: Diversity
and Universals. Cambridge: Cambridge University Press. 1998

(5)Moncrieff, J. and Kirsch, I. Efficacy of antidepressants in
adults. British Medical Journal, 2005, 331, 155-157, 16th July.

(6)Brown, G. and Harris, T. Social Origins of Depression London:
Tavistock. 1978.

(7)Bhaskar, R. Reclaiming Reality. London: Verso. 1991

Competing interests:
None declared

Competing interests: No competing interests

01 May 2006
David Pilgrim
Clinical Dean
Teaching Primary Care Trust for East Lancashire, Guide Business Centre, , Blackburn BB1 2QH