The theoretical implications of equating the melancholic states of past eras with today's depression are explored. These include the presuppositions of the descriptive psychiatry so influential in twentieth century classification, which attempts to identify and describe mental disorders without reference to underlying causes. It also includes claims made about different forms of masked, and non-Western depression, and the new "drug cartography" assigning psychiatric categories based on psychopharmacological effect. An evaluation of the relative merits of descriptivist and causal ontologies, together with (...) an assessment of the similarities and differences between melancholia and depression, suggest the conclusion that these two conditions are misleadingly equated. (shrink)

Since the publication of Listening to Prozac there have been many debates about how and why Prozac and other similar drugs are prescribed. The articles that follow take up debates about what conditions such drugs can and should address, questions about authenticity in using drugs for psychic well‐being, and concerns about what means we morally endorse in projects of self‐creation. The contributions from Carl Elliott, Peter Kramer, James Edwards, and David Healy derive from a project supported by the Social Sciences (...) and Humanities Research Council of Canada, “Enhancement Technologies and Human Identity.” Psychiatry, like the Prozac it prescribes, aims to enhance the patient's internal psychic well‐being. Yet what ails many may be not an internal state like depression or anxiety, but alienation. And the experts of the self to whom we turn cannot “cure” our collective form of life in which alienation takes root. (shrink)

Spanning 24 centuries, this anthology collects over thirty selections of important Western writing about melancholy and its related conditions by philosophers, doctors, religious and literary figures, and modern psychologists. Truly interdisciplinary, it is the first such anthology. As it traces Western attitudes, it reveals a conversation across centuries and continents as the authors interpret, respond, and build on each other's work. Editor Jennifer Radden provides an extensive, in-depth introduction that draws links and parallels between the selections, and reveals the ambiguous (...) relationship between these historical accounts of melancholy and today's psychiatric views on depression. This important new collection is also beautifully illustrated with depictions of melancholy from Western fine art. (shrink)

Explanatory models in psychiatry reflect what clinicians deem valuable in rendering people's behavior intelligible and thus help guide treatment choices for mental illnesses. This article outlines some key scientific and ethical principles of clinical explanation in twenty-first century psychiatry. Recent work in philosophy of science, clinical psychiatry, and psychiatric ethics are critically reviewed in order to elucidate conceptual underpinnings of contemporary explanatory models. Many explanatory models in psychiatry are reductionistic or eclectic. The former restrict options for diagnostic and therapeutic paradigm (...) choice, while the latter lack a well-defined theoretical basis. These two methodological approaches stand in a dialectical relation to one another insofar as clinicians often move from one approach to its antithesis, ultimately seeking a synthesis of the two approaches that satisfies clinical needs. Pragmatic considerations can help to transcend the reductionism/eclecticism dialectic. In the absence of a completed science of mental disorders, psychiatrists must tolerate ambiguity and uncertainty as they strive to integrate diverse explanatory concepts in a rigorous and evidence-based fashion. A pragmatic explanatory model in clinical psychiatry must focus on favorable treatment outcomes for patients by respecting the pluralistic, participatory, and provisional nature of psychiatric explanation. (shrink)

In the Western aesthetic of melancholy, alienation and authenticity walk hand in hand, and therapies that change affective states—especially drugs like Prozac—are philosophically suspect. This is not a necessary state of affairs. What would be the central philosophical questions in a culture whose aesthetic values rose from the well‐springs of optimism?

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 57-62 [Access article in PDF] Listening to People Or Listening to Prozac?Another Consideration of Causal Classifications Jennifer Hansen Keywords causal classification, descriptivism, melancholia, neurasthenia, depression, cultural relativism. The shape and detail of depression have gone through a thousand cartwheels, and the treatment of depression has alternated between the ridiculous and the sublime, but the excessive sleeping, inadequate eating, suicidiality, withdrawal from social interaction, (...) and relentless despair are all as old as the hill tribes, if not as old as the hills. In the years since man achieved the capacity for self-reference, shame has come and gone; treatments for bodily complaints have alternated and crossed with treatments for spiritual ones; pleas to external gods have echoed pleas to internal demons. To understand the history of depression is to understand the invention of human being as we now know and are him. Our Prozac-popping, cognitively focused, semi-alienated postmodernity is only a stage in the ongoing understanding and control of mood and character. (Solomon 2001, 286) ALTHOUGH ANDREW SOLOMON clearly believes that "the shape and detail of depression have gone through a thousand cartwheels," Jennifer Radden gives us pause before assuming that depression is just another name for Dame Melancholy. Solomon's claim depends on a deeper metaphysical claim about the nature of depression and its causes. The current method of psychiatric nosology, descriptivism, does not necessarily support equating melancholia and depression. Furthermore, it appears that adopting descriptivism as the sole method of classifying mental disorders commits us to cultural relativist psychiatry. Below I reconsider whether we want to rule out causal classifications and suggest that embracing both descriptivism and causal classifications offer us greater possibilities in understanding human illness and culture.Although the occasion for Jennifer Radden's essay is to investigate whether or not melancholia and depression refer to the same thing, her essay detours into a consideration of extra-descriptivist models of psychiatric illness versus the descriptivism of current psychiatric nosology. This detour turns out to be warranted; her purely academic question yields to a timelier question concerning the proper methodology for classifying mental disorders. Whereas debates about psychiatric nosology are perennial, the recent success of the new generation of antidepressants [End Page 57] is reviving biological psychiatry and its search for the neurochemical origins of depression. Hence, embedded in Radden's question concerning whether or not melancholia is the same thing as clinical depression, is another important question concerning the causes of mental illness, particularly depression.Currently, with its descriptivist approach, the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not classify mental illness, such as clinical depression, based on underlying causes. The cluster of symptoms and behavioral signs that lead a clinician to diagnose one as depressed that are contained in either the DSM or the International Classification of Diseases (ICD) may be too fuzzy or elusive to give any clear distinction between major depression, mild depression, and the blues. For example, one group of epidemiologists points out that [t]he DSM-III, DSM-III-R, and DSM-IV acknowledge that depression, like many mental disorders, has no currently obvious natural classes... If natural classes of depression exist, then their nosology awaits the discovery of distinct and reliable genetic, biological, clinical, or other predictors of risk, severity, or clinical course. Clinicians have a tradition of separating depressions into subtypes; however, this subtyping has not yet led to clear-cut delineations of syndromes in populations. (Kaelber 1995, 4) The evidence is still insufficient to establish the biological or psychological origins of depression. Although many theories exist that explain why people become depressed, scientifically we are not yet in a position to determine which is the right theory. From a pragmatic perspective, however, whether or not we know what causes depression, we can nonetheless attempt to alleviate suffering from depression. And it is with this goal in mind that the DSM-IV and ICD-10 classify mental disorders.Now, given that our current methodology for psychiatric nosology does not establish causes, it is also insufficient for determining what... (shrink)

This paper aims to arrive at a coherent concept of one sort of mental disorder and of appropriate methods of treating it. Incoherence arises because of the conflict between modern conceptions both of morality and of health and illness and the necessary use of moral terms in defining what makes some mental disorders. Modern moral philosophy and modern conceptions of health and illness imply that health is a non-moral good, and so that illness is a “disorder” in a non-moral sense. (...) Ancient ethics, on the other hand, allows states as well as actions to be morally evaluated, and so for the notion of a moral order or disorder which is not consciously chosen. It is argued that some kinds of mental disorder can be modeled on this conception of an unchosen moral disorder, and that the appropriate treatment for them is that species of moral education that we call “psychotherapy.”. (shrink)

Major depression is a disorder of the mind caused by dysfunction of both the body and the brain. Because it is a psychiatric illness and psychiatry is a branch of medicine, the question of how mind and body interact in depression should be treated as a medical rather than metaphysical mind-body problem. The relation between mind and body as it pertains to this illness should be construed in teleological rather than causal terms. Mental states like beliefs and emotions serve an (...) adaptive purpose by constraining the physiologic systems involved in the body's stress response, thus preserving homeostasis and protecting us from various disorders. Depression results when the mind fails it its constraining role. (shrink)

The current dominant paradigm of mental disorder is that psychopathology is a deviation from normal physiological functioning of the brain. This paradigm is closely allied to the identity theory of mind in philosophy, which holds that mental phenomena are identical with the physical state of the brain. The assumptions of the biological model have policy implications, regardless of the utility or ‘truth’ of the paradigm, which should be made explicit for the assessment of ethics in mental health policy formulation. The (...) nature of mental phenomena has been debated throughout history, without consensus. Several critiques of the biological model are offered to encourage enquiring scepticism. The policy implications discussed are political conservatism, broadened rationales for forced treatment, utility in managed care, and the use of medical necessity criteria to allocate treatment. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.3 (2002) 265-269 [Access article in PDF] The Psychology and Physiology of Depression Walter Glannon Trauma and stressful events can disrupt the physiologic homeostasis of our bodies and brains. The physiologic stress response consists of neural and endocrine mechanisms whose function is to reestablish homeostasis. These mechanisms include the secretion of glucocorticoids (cortisol) and catecholemines (epinephrine and norepinephrine). Once an external event has ceased to (...) be a stressor or threat to a human organism, an integrated system of negative feedback loops inhibits the continued production of these hormones and effectively shuts down the stress response. These mechanisms are adaptive in the sense that they ensure the survival of the organism by reestablishing homeostasis. But prolonged exposure to real or perceived stressors can trigger prolonged secretion of stress hormones, thereby disrupting the feedback systems and causing a cascade of pathogenic events. The stress response is a double-edged sword. An acute stress response can protect an organism from external threats and reestablish homeostasis. But a chronic stress response can cause the body's defenses to become damaging rather than protective and to result in various disorders. Acute stress responses are adaptive. Chronic stress responses are often maladaptive and pathogenic.In "Depression as a Mind-Body Problem," I characterized major clinical depression as a disorder resulting from a maladaptive chronic stress response (Glannon 2003). Specifically, I argued that depression often results when our beliefs and emotions are out of proportion to the true nature of external events. The mind prolongs rather than constrains the physiologic stress response. Depression is not a disorder of the brain alone or the mind alone, however. Endocrine and immune dysfunction can contribute to the dysfunction in the brain and central nervous system that are involved in depression. Moreover, the contents of the mental states that initiate the sequence of events leading to depression are reflections of the person's natural and social environment. Thus, a satisfactory account of depression requires an analysis of the interconnections among the central nervous, endocrine, and immune systems, as well as the mind and the environment. All of these factors support the description of depression as a psychoneuroimmunologic disorder.Mike Martin (Martin 2003) and Thomas Fuchs (Fuchs 2003) discuss important aspects of depression that I did not elaborate in my paper. Martin argues that I fail to distinguish between depression as a mood and depression as a disorder. This is pertinent to the distinction evolutionary psychiatrists draw between moods that are adaptive and moods that are maladaptive. In contrast to my negative characterization of depression, Martin also makes a case for the positive [End Page 265] contributions of depression to meaningful life. Fuchs explores the notion of the brain as an organ of translation enabling patients to have meaningful subjective experience. The emphasis on subjectivity has important implications for potential preventive and therapeutic interventions for depression. For whether a person perceives an external event as a stressor may play a crucial role in the physiologic stress response. I will address the main points of these two authors in turn.Contrary to what Martin claims, I explicitly defined chronic depression as an affective (mood) disorder. My focus was on the clinical definition of major depression as a moderately severe to severe chronic disorder. It consists of affective, cognitive, and even physical dysfunction that interferes with a person's ability to carry out the normal tasks of daily life. This characterization of major chronic depression distinguishes it from milder forms of depression, such as dysthymia. Because these milder forms do not involve the same type or degree of dysfunction as more severe forms, they are not appropriately characterized as pathologies. For this reason, I focused on Nesse's (2000) discussion of depression rather than on his discussion of low mood. In fairness to Nesse and Stevens and Price (2000), not all forms of depression are pathologic according to the evolutionary view they defend. Some passive aspects of mild depression may be useful in alerting us to dangerous or wasteful behavior. It does seem plausible to describe depressed moods as falling along a continuum from those that... (shrink)

Collection of essays on the connection between medicine and literature and how novelists and physicians are both, in a sense, diagnosticians; the book focuses, in particular, on Walker Percy, a writer who had trained as a pathologist.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 53-55 [Access article in PDF] A Pragmatic Consideration of the Relation between Depression and Melancholia David H. Brendel THE MELANCHOLIA OF THE PAST and the major depression of the present are extraordinarily complex notions that represent different things to different people. With her compelling article "Is This Dame Melancholy? Equating Today's Depression and Past Melancholia," Jennifer Radden makes an important contribution to the (...) debate on whether these concepts are identical, overlapping, or distinct. Exploring both conditions from descriptive and causal points of view, Radden appropriately concludes that fully equating the two of them would constitute a "troubling oversimplification." Her line of reasoning runs as follows. Because past descriptions of melancholia and current descriptions of major depression are marked by dissimilarities (such as the genius and creativity associated with the former and the self-loathing and emphasis on loss associated with the latter), only an underlying causal base common to both conditions would justify our equating them. But the cause (or causes) of melancholia and depression remain mysterious. Thus, although Radden acknowledges that a causal explanation might yield substantial benefits ("research possibilities, further hypotheses, and even hope of prevention, or cure"), she suggests that we remain in a descriptive mode when comparing the two conditions and conclude that they are not one and the same.Radden's argument that past melancholia and contemporary depression are descriptively distinct is convincing and, I think, indisputable. But I would like to challenge and expand upon some of her ideas about considerations of causality and about the role of pragmatic reasoning in working out the relation between melancholia and depression. First of all, although Radden is correct that the cause of many (or perhaps most) depressive states is unknown, she underrates the extent of the empirical knowledge that we have acquired about the causation of depression and, in so doing, undervalues the relevance of causal reasoning to making the melancholia/depression distinction. Recent empirical research has revealed that major depressive episodes can result from brain lesions such as left-sided strokes or metabolic disorders such as hypothyroidism (Yudofsky and Hales 2002). Psychosocial research, moreover, has suggested that stressful life events also can be understood as causes of depression (Kendler, [End Page 53] Karkowski, and Prescott 1999). These findings provide some hope that the identification of causes of various clinical states is a real possibility. Identification of such causes, I believe, could empower us to make some plausible claims about the similarities or differences between past melancholia and current depression. A melancholic individual like van Gogh, for example, had a different illness than a contemporary stroke patient with major depression in a present-day hospital, not only on the basis of descriptive distinctions between their conditions, but also on the basis of the causes of their respective states. Although of course we cannot know the cause of van Gogh's melancholia, we can reasonably assume that it was not the result of a left-sided stroke due to the absence in his case of other clinical deficits that usually result from such a stroke (such as language and motor deficits). Plausible assertions about the causes of melancholic and depressive states would add to the robustness of any claims regarding the distinctness of the conditions.Conversely, careful consideration of the etiology of various clinical presentations might prompt us to hypothesize a shared pathophysiology and thereby lead us to believe that they are essentially identical conditions. It is difficult or impossible to discover a cause of melancholia in individuals who lived in past eras. But we might achieve our goal by comparing well-defined major depression to various forms of what Radden calls "masked depression," such as those seen in cross-cultural settings, where the subjective symptoms of sad mood are absent but numerous somatic signs of depression are observed. If it turned out that major depression and masked depression had the same cause, then differences in their clinical phenomenology would become merely surface differences that belie a shared etiological process. How might one discover the existence of such a process... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.3 (2002) 255-259 [Access article in PDF] On the Evolution of Depression Mike W. Martin Keywords: Depression, morality, mental disorders, psychobiology, evolutionary psychiatry. In "Depression as a Mind-Body Problem," Walter Glannon outlines a psychosocial-physiological explanation of depression as a psychological response to chronic stress—today, especially social stress—in which cortisol imbalances disrupt neurotransmitters. Accordingly, treatment for depression should combine psychopharmacology and psychotherapy—a valuable reminder in light (...) of the current restrictions on funding for health care (Hobson and Leonard 2001). My comments focus, however, on Glannon's objections to evolutionary theorists who explain our capacity for depression as adaptive to the natural and social environment. His objections are implausible because he fails to distinguish depression as a mood and a disorder. What Is Depression? Explaining the psychology, sociology, physiology, and evolution of depression presupposes knowing what depression is and hence what is being explained. As a blunt but important distinction, let us contrast depression as a mood and as a mood disorder.As a mood, depression is a state of low spirits, typically involving painful and low affect (of a kind needing further specification). Not all negative low moods are depressions. It is notoriously difficult to distinguish depression from grief, sadness, gloom, and a host of additional ways to feel down—especially because today many people use "I'm depressed" as a blanket expression for virtually any low mood. For the purposes of this paper, it is not necessary to attempt a full-blown analysis of depressed moods (and emotions). I would emphasize, however, that depressed moods involve values. They involve negative evaluations of ourselves, major events in our lives, life in its entirety, or the values that have been guiding us. Typically, to be depressed is to experience such things as feelings of worthlessness, dejection about failures, despair and hopelessness, and loss of caring and commitment. Thus, we might be sad or grieving but not depressed because we retain a solid grip on what is valuable and worthwhile. In any case, there should be no general presumption that depressed moods are all bad or undesirable. Instead, we should be prepared to appreciate the importance of depressed moods in connection with questions of value, identity, and even moral insight (Martin 2000). Depressed persons are not necessarily sick.In contrast, depression as a mood disorder is, by definition, pathologic. Moreover, usually it is not a depressed mood, although it involves depressed moods. On the one hand, depression as a disorder is defined as pathologic, a notion that is itself understood in terms of values—the values of health and, indirectly, moral values that define what is culturally acceptable. Thus, even severe [End Page 255] grief can be nonpathologic, even though it involves depressed moods, when it is within the range of "culturally-sanctioned responses" (APA 2000, xxxi). On the other hand, only sometimes is depression a single pathologic mood, as in major depressive episodes that can strike with a terrifying and suicidal severity (APA 2000, 375). Usually, however, the pathology is not a single depressed mood, but instead a longer-term state involving recurring depressed moods and additional features, such as poor concentration, insomnia, poor appetite or overeating, and so on. For some purposes, such as research funding and billing insurance companies and government health providers, these pathologies can be equated with what is currently in the DSM. Yet, there are many additional states of suboptimal health, in which the DSM criteria are only partly met.What does Glannon mean by depression? He does not define it, but he makes it perfectly clear that he intends depression as a disorder. Or rather, it is a set of mental disorders, including the "depressive disorders" of major depressive disorder, dysthymic disorder, depressive disorder not otherwise specified, and a variety of bipolar disorders and some anxiety disorders. Glannon sometimes indicates his primary topic is "severe depression," which of course is not a DSM category (nor always a mark of pathology). For the most part, however, he says his topic is "chronic depression," which might suggest dysthymia, "a chronically depressed mood for most of... (shrink)