Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care

This line from Shakespeare's Romeo and Juliet is perhaps the best-known articulation of the idea that names do not matter—that the essence of something remains the same regardless of what we call it. Just as Juliet learned that names can have profound political and social implications regardless, the process of preparing DSM-5 reminds us that the words used to describe psychiatric disorders do as well. The book Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care, by rhetorician Kimberly Emmons, is a timely exploration of the impact of the words used to describe depression.

Dr. Emmons' work stems from the premise that words both reflect and shape cultural expectations, including illness and gender role identities. With this in mind, she analyzed the rhetoric of ads, cartoons, memoirs, self-help texts, news sources, pamphlets, and websites about depression. She then conducted semistructured, small group interviews with women with subsyndromal depressive symptoms as well as with mental health providers to further elucidate reactions to the prevailing public discourse about depression. The result is a persuasive explication of the ways in which rhetoric about depression influences self-perceptions, health-related behaviors, and clinician-patient relationships, sometimes by historical happenstance but often on purpose.

Black Dogs and Blue Words traces the evolution of the contemporary concept of depression from its modest origins as a means of standardizing data collection in the first DSM to its current ubiquitous place within popular culture. According to Emmons, the use of the word “depression” to describe both a serious disorder and a normal emotion creates a lexical imprecision that has been exploited by institutions, such as pharmaceutical companies, to broaden the group of people who might self-identify as depressed and therefore seek treatment. This trend has intensified since the advent of direct-to-consumer pharmaceutical advertising and web-based medical information sources. Emmons' analysis of ad content reveals that most highlight symptoms that are commonly experienced as a part of everyday life. The self-diagnosis encouraged by such ads as well as by symptom checklists on websites and in magazines is usually followed by the command, “Talk to your doctor about (name of anti-depressant).” This can powerfully shape the clinician-patient encounter, constricting the dialogue to a more narrowly defined discourse (symptom list) and solution (medication). A narrow conceptualization of depression as solely caused by a neurotransmitter imbalance and cured by antidepressants is further underscored by popular metaphors (e.g., medication as a key that fits into a lock) and stories.

In addition to the influence of rhetoric on illness perceptions and behavior, Emmons points out the ways in which discourse about depression defines what a nondepressed “normal” person is supposed to be like. For example, when a brochure from the National Institute of Mental Health defines people with dysthymia as “lacking in zest and enthusiasm for life,” this implies that people should strive for zest and enthusiasm, perhaps taking medication to achieve this. Emmons contends that rhetoric about depression is especially influential in reinforcing gender roles. For example, depression is frequently portrayed as intrinsic to the self of a woman, but more often portrayed as a physical experience for a man. Further, public discourse about depression often suggests that it is a depressed woman's responsibility to seek treatment so that she can perform her caretaking duties, while men with depression are more often portrayed as being taken care of by wives or others.

Emmons calls for a return of curiosity so that both depression sufferers and clinicians can go beyond the constraints of contemporary discourse when their experiences do not fit narrow definitions. She recommends rhetorical competency, a discerning awareness of the influence of rhetoric on self-definition and perception. Such awareness seems especially important now as we collectively and publicly debate about the words that will become ensconced in DSM-5. Controversies about diagnostic terms in DSM-5 stem mostly from competing rhetorical agendas. Should we choose terms that reduce stigma? Favor labels that raise the importance of psychiatry because they sound more technical (1)? If we do, how will that affect people's self-images, perceptions, behaviors, and clinical experiences?

You may not approve of everything you find in Black Dogs and Blue Words. Emmons herself uses rhetoric strategically, often citing conclusions before evidence and basing her assertions on selective data. Yet if reading this book helps us think more carefully about the rhetorical tug of the words we encounter as well as the words we choose in speaking about depression, it is well worth it.