The Age of Melancholy: “Major Depression” and Its Social Origins

According to the World Health Organization, depression ranks fourth among the 10 leading causes of the global burden of disease and is expected to rise to second within the next 20 years. In this slim treatise, Dan G. Blazer, J.P. Gibbons Professor of Psychiatry and Behavioral Sciences at Duke University Medical Center, looks at the social origins of depression, and in the process makes an impassioned plea for revival of social psychiatry. He believes that coincident with the rise of depression in the past few decades, American psychiatry has seen the rise and fall of social psychiatry and its cohort community psychiatry and the ascendance of biological psychiatry and its helpmate descriptive psychiatry. However, as significant and far reaching as these developments have been, psychiatry has overlooked the contribution of social factors to the causation of psychiatric illness in general (1), and depression in particular. An understanding of these societal factors will go far in treating and perhaps preventing depression in our age, as well as providing a road map for the revival of social psychiatry.

This book has four sections and in section I, titled the “Diagnosis of Depression,” the author discusses the birth and growth of major depression as a social phenomenon and as a diagnosis. After the Second World War, simultaneous with the growing popularity of psychoanalysis, depression was seen as occurring in reaction to the events in one’s life. In response to the backlash against psychoanalysis, depression began to be conceptualized mainly as a medical illness. Now major depression is treated as a “thing” that happens to people due to chemical imbalance much like a stroke that happens due to physical factors.

In section II, titled “Social Psychiatry,” the author reviews the birth, the growth, and the retreat of social psychiatry. He believes that emotional suffering is a social and personal experience, and the way we communicate our emotions depends on the standards society sets for their expression. Social psychiatry—the study of our feelings and behaviors within the context of society—became a dominant force in the 1950s and 1960s because of the support of the ambitious social agenda of Presidents Kennedy and Johnson as well as because of the work over the preceding half century of sociologists such as Emil Durkheim and psychiatrists such as Adolph Meyer and Harry Stacks Sullivan. This flowering of social psychiatry was followed by its very quick retreat, and Blazer provides a detailed account of various factors that contributed to it.

In section III, “The Frequency of Depression and the Lesson From War and Society,” the author reviews two waves of epidemiological studies, each emblematic of psychiatry’s existing priorities. The earlier wave, which included the Sterling County study and the Midtown Manhattan study, focused on social phenomena such as a community’s degree of disintegration and the occurrence of psychiatric illness in its wake. The second wave consisted of the Epidemiological Catchment Area (ECA) study and the National Comorbidity Survey (NCS) and targeted measurement of the prevalence and distribution of specific DSM-III and DSM-III-R disorders; this emphasis on phenomenology heralded the birth of descriptive psychiatry and the reification of such phenomena as depression. In a similar vein, he demonstrates how our understanding of war syndromes went through several iterations and war trauma, much like depression, is currently being viewed like a medical illness.

The chapter “Things Fall Apart: Society and Depression in the 21st Century” presents the core argument of this book: our current age is experiencing the rise of depression as a major illness of our time. Dr. Blazer offers a critical examination of various Western intellectual traditions of the past 200 years such as enlightenment, modernity, and postmodern predicament to explain such a trend. In this context, he sketches the shift of psychiatry’s focus from the meaning of an illness to an individual to its current emphasis on biological basis of diseases and issues of diagnostic reliability and validity. Dr. Blazer believes that in the process, psychiatry has traded depth for precision.

Finally, in section IV, “The Revival of Social Psychiatry,” Dr. Blazer describes how social psychiatry can undergo a renaissance, supported by a foundation of empirical research and by avoiding the social activism and the excesses of the 1960s. He examines how a study of depression in the workplace and the social ecology of depression can contribute to the launching of the new social psychiatry as a scientific discipline. He further discusses how a study of emotion, such as depression, can demonstrate the crucial link between body and society by examining related concepts of “social zeitgebers” and “allostatic load.” He concludes by cautioning society against ignoring its most fundamental ills and treating itself with a medical panacea, much like Aldous Huxley’s fictional drug “Soma” was used to placate people in the Brave New World.

This well-researched and well-written text provides an excellent overview of the rise and fall of social psychiatry, as well as the evolution of depression from a psychological disorder to a biomedical illness. In its broad canvas, it captures many social and intellectual forces that contributed to this phenomenon. Dr. Blazer adopts a well balanced and scholarly approach to the study of a much overlooked topic that evokes strong emotions in its adherents. It is remarkable how much is accomplished in these 211 pages in terms of covering the history, reviewing the broad social backdrop, and setting out a modest research agenda for social psychiatry. The chapter “Things Fall Apart: Society and Depression in the 21 ^st Century,” which addresses modernism and postmodern critique, is especially exhaustive and is a must read for anyone interested in studying larger intellectual developments in society and their impact on psychiatric thinking. As much as this reviewer loved reading this book, there were some shortcomings that need to be pointed out. Dr. Blazer makes a powerful argument that psychiatry has sacrificed its focus on depth in favor of diagnostic and scientific robustness, and a revival of social psychiatry will correct this deficit. It is not clear how it can be accomplished without discussing the role of the mind, which was not in the purview of this book. It seems that the author is aware of this dilemma as per the following statement: “Although the study of the social origins of depression might be an interesting intellectual pursuit, how might it change the relationship between doctor and patient? …. Does therapeutic encouragement to discover ways to better adapt to the social environment always meet the needs of the patient?” (p. 15).

The next critical issue is whether the present day psychiatrists are any better skilled to practice community psychiatry. While reviewing factors that contributed to the fall of community psychiatry, Dr. Blazer points out: “Though concern for community prompted community intervention in theory, community intervention and social activism felt strange to mental health professionals. In addition, psychiatrists and other mental health workers had gained their experience within the doctor-patient framework. Their training did not produce the skills needed for community intervention” (p. 75). These sentiments still hold true today because the one-to-one relationship between the psychiatrist and the patient continues to be the bedrock of all professional relationships regardless of whether one is practicing psychopharmacology or psychotherapy. Similarly, the author does not provide how social circumstances now are more conducive to the revival of social psychiatry than they were in the 1950s and 1960s, when American society was awash with funds, high ideals, and great willingness to countenance social engineering in contrast to the current paucity of resources and attempts to dismantle social institutions created in the 1960s. In the last chapter, the author’s likening current antidepressant use to the use of fictional drug “Soma” seems somewhat overstated in the context of the recent decline in use of antidepressants secondary to society’s concerns about their efficacy as well as their potential to generate suicidal thoughts. Likewise, as the rise in use of complementary medicine in our society has shown, nonpharmacological ways of reducing distress such as meditation are becoming more popular than taking medications to manage ones discomfort.

In addition, the author, in his attempt to be conciliatory to the other major schools, continuously soft-pedals his critiques of biological and descriptive psychiatry. This approach perhaps is understandable given his stated aim of positioning the new social psychiatry as a complement of the other major paradigms and not as their competitor. However, one begins to wonder if the author sees virtue in every major paradigm, why propose a revival of social psychiatry at all? In addition, the attention given in this book to a discussion of social class and its contribution to illness is somewhat sparse (2) .

The title of the book is somewhat misleading: A reader might be forgiven for thinking that the main focus of the book is an “Age of Melancholy,” while in actuality, it is on social psychiatry in equal measure. Furthermore, by de-emphasizing culture in his discussion of factors that contributed to the rise of depression, Dr. Blazer provides an incomplete argument. We currently live in a society felicitously named “Flat World” (3) that is filled by high anxieties caused by the phenomenon of globalization and its attendant danger of terrorism. Consequently, one wonders whether our age is any more depressogenic than those other times in history. In the context of the current war on terrorism, there seems to be more of a pervasive sense of anxiety and apprehension than depression in our culture. Curiously, in his broad review of social forces, the author does not mention the contribution of the post 9/11 climate to the current age of melancholy.