The Age of Melancholy

In the book The Age of Melancholy by Dan G. Blazer, a psychiatrist at Duke University, looks at the effects of the medicalization of psychiatry on the definition and formulation of major depression. He specifically rues the loss of a social perspective on the diagnosis and understanding of depression as a condition, an illness, and a state. He describes the gradual disconnection of the social milieu from the internal world, with unfortunate consequences not only to those who suffer from depression but also to society as a whole.

Dr. Blazer traces the history of social psychiatry, which constitutes an important part of the book. This material will prove fascinating, particularly for younger readers who may have received their psychiatric training after the heyday of social psychiatry. He also details the development of the term "major depression" as a symptom of the medicalization of a far more complex condition. He deplores the reduction of the experience of depression to a mere chemical imbalance and implores readers to expand their notion of depression, particularly its causation to disharmony between the person and his or her cultural and social milieu.

The author provides other models for the etiology—or at least for contributing factors to the onset—of depression, including stress, trauma, war experiences, and other social contexts. In particular, he examines the development of our thinking about depression in the context of societal evolution from the pre-Enlightenment world, with its emphasis on authority, to the rise of the Modern, with its emphasis on reason and the power of the individual. This same development changed Western thought from a belief in the supernatural, "natural law," and groups of people sharing similar beliefs and experiences to a belief in reason, in which scientific inquiry and individual autonomy predominated. This paved the way for illness, particularly depression, to be conceived as arising from within the individual as a result of observable, or at least discoverable, defects rather than being generated by unsatisfactory conditions within a social milieu. Furthermore, instead of minimizing the suffering of those with depression he believes and urges us to share in the belief that depression causes suffering that is only partially relieved by pharmacological treatment.

The book argues that in many ways, major depression is not like other medical or even many psychiatric illnesses. For example, he states that people with depression don't necessarily regard themselves as ill—nor do many people with other psychiatric illnesses, a challenge to psychiatrists—but rather identify their problems as deriving from a social context, such as losses and stresses at home and at work. It also presents interesting data that many people who meet DSM-IV criteria for major depression do not themselves act as if they are so impaired and generally meet their social and work obligations. Therefore, Dr. Blazer concludes, the medical model that defines major depression as an illness is, at best, inadequate and urges an approach to diagnosis and treatment that is multidimensional, even beyond the now hackneyed biopsychosocial model.

What I enjoyed most about this book was the history. As an erstwhile trainee at an urban community mental health center who saw the community mental health care movement as a way to incorporate now-rigorous biological science into the complex psychosocial needs of its neighbors in the community, I felt my own dedication to community psychiatry renewed. And yet, toward the end of the book, Dr. Blazer is careful to advise the reader not to throw the baby out with the bathwater, acknowledging that even with the multifactorial etiology of depression, antidepressant medication plays a role in the amelioration of this common and painful condition.

The book is studded with examples that are meant to relate to the content at hand. The author is less successful at this. I found many of the examples oblique and only very tangentially related to the particular chapter or idea presented. The author's intent is evident despite this flaw.

The Age of Melancholy will delight all veterans of the community psychiatry movement and those whom they trained. It is so good to be reminded of psychiatry's history as a leader in public health and social activism, and younger psychiatrists and other therapists are well reminded of this. Hopefully, books such as The Age of Melancholy will inspire trainees and newly minted psychiatrists that the treatment of mental illness must venture beyond the boundary of the prescription pad to really meet patients where they live.