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Listening to People Or Listening to Prozac?
Another Consideration of Causal Classifications
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...