From a diagnostic‐therapeutic to a social‐existential response to ‘depression’

Pages6-12
Published date01 June 2006
Date01 June 2006
DOIhttps://doi.org/10.1108/17465729200600013
AuthorDavid Pilgrim,Christopher Dowrick
Subject MatterHealth & social care
This paper provides a critique of the current diagnostic and therapeutic or thodoxy in relation to the
concept of depression. It argues that there are substantial problems with the conceptual validity of
the diagnosis, and that both empirical and moral objections can be raised to the current preference
for a therapeutic response. It makes the case for an alternative that conceptualises misery,distress
and sadness as existential states arising in particular social and biographical contexts. Its central
argument is that the varieties of determinism that underpin the diagnostic and ther apeutic discourse
obscure important aspects of human agency and diminish options for its expression in the life world
of the people receiving the diagnosis of ‘depression’.On this basis the focus of interest for health
workers becomes the ability, working with patients, to discover dignity, meaning and purpose in the
midst of suffering and distress.
From a diagnostic-therapeutic
to a social-existential response
to ‘depression’
David Pilgrim
Visiting professor
School of Population,
Community and
Behavioural Sciences
University of Liverpool/
Honorary professor
Lancashire School of
Health and
Postgraduate Medicine
University of Central
Lancashire
Christopher Dowrick
Professor of primary
medical care
School of Population,
Community &
Behavioural Sciences
University of Liverpool
Correspondence to:
Professor David Pilgrim
Teaching Primary Care
Trust for East Lancashire
Guide Business Centre
School Lane
Blackburn BB1 2QH
david.pilgrim@
bwdpct.nhs.uk
Key words:
depression
diagnosis
therapy
determinism
agency
OPINION
6journal of public mental health
vol 5 • issue 2
This paper has three main aims. First,
some conceptual problems with the
diagnosis of ‘depression’ will be
examined. Second, limits of the bio-
medical orthodoxy about the diagnosis
will be summarised. Third, a case will be made for
moving beyond versions of determinism when
understanding and responding to people who might
receive the diagnosis. This is a case for a shift from a
diagnostic-therapeutic frame to one in which the
wide range of symptoms currently given the single
reductionist label of ‘depression’ are understood in
their particular biographical and social context.
Depression has now entered the vernacular,
where it has displaced many other descriptions of
distress, sadness and misery. It has become a single
category to describe a range of thoughts, feelings and
experiences from temporary despondency to suicidal
anguish. The diagnosis is so common that it is not
only described confidently by lay people, it is also
considered by the World Health Organization to be
the largest epidemic impacting on modern developed
societies (Murray & Lopez, 1995). Some lay people
even now deploy the term ‘clinical depression’ to
indicate a particular state to be distinguished from
everyday unhappiness. As has frequently been
observed, misery has been professionalised within the
secular framework of psychiatry (de Swaan, 1990;
Bracken & Thomas, 2005).
Seligman (1975) described depression as the
‘common cold of psychiatry, at once familiar and
mysterious’ (Seligman, 1975). A brief history of the
development of the concept highlights this point.
Brief historical overview
In the Victorian period two early versions of the
diagnosis appeared: melancholia and mopishness.
These were largely class-based descriptions, with
poorer patients tending to attract the latter
description. Both were attached to mad asylum
inmates; the notion of neurotic-reactive depression
really came to the fore during the 20th century as
part of the discourse about ‘shellshock’ (Stone,
1986; Rogers & Pilgrim, 2003), emerging as a
diagnostic description within Kraepelinian
psychiatry. Before this shift from insanity to a
broader view about a reaction to loss of people or
control, depression was seen as a pole of psychotic
swings of mood and distinguished from ‘dementia
praecox’ (now dubbed ‘schizophrenia’), which was
considered to have a poorer prognosis than ‘manic-
depression’ (Kraepelin, 1921). The attribution of
©Pavilion Publishing (Brighton) Ltd

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