In a recent essay published in the New York Times, philosopher Gary Gutting1 raised concerns about DSM-5 revisions in the definition of depression. In particular, Gutting—like many others—worries that eliminating the bereavement exception in the guidelines for the diagnosis of MDD represents a dangerous move. Why? As Gutting1 puts it:
Because, first of all, psychiatrists as such have no special knowledge about how people should live. They can, from their clinical experience, give us crucial information about the likely psychological consequences of living in various ways (for sexual pleasure, for one’s children, for a political cause). But they have no special insight into what sorts of consequences make for a good human life. It is, therefore, dangerous to make them privileged judges of what syndromes should be labeled “mental illnesses.”
What bothers Gutting and many other observers is the sense that perfectly normal, appropriate behavior and responses (eg, grieving after the death of a loved one) are being unduly pathologized. This criticism derives from a line of argument going back several decades to the works of people such as sociologist Peter Conrad, philosopher Michel Foucault, and clinician Thomas Szasz.2-4 And the topic has been raised and discussed in Psychiatric Times.5
I have no intention in this context to pile on more criticism of the framers of the DSM, nor do I seek to justify their choices. Rather, I am more interested in how the expansion of the clinical definition of depression seems to be emblematic of a process widely referred to as medicalization.
To what extent is it fair to characterize this and a variety of other shifts in thinking and practices as examples of what Peter Conrad2 calls “the medicalization of society”?
To answer that question requires first asking ourselves just what is meant by the notion of medicalization. Conrad2 supplies one answer in the subtitle of his 2007 book—“the transformation of human conditions into treatable disorders.” In a set of lectures in 1975, Michel Foucault3 offered a similar definition, identifying a number of changes he associated with the process of medicalization: the insinuation of psychiatry into new areas of public administration, the growing reliance of institutions on psychiatric expertise, and the increasing pathologization and somaticization of odd behaviors. On the basis of these characteristics, it is hard to quarrel with Allan Horwitz and Jerome Wakefield6 in seeing sadness as one of the human attributes more recently to have undergone this clinical makeover.
Although it may not be terribly difficult to find plenty of historical instances that seem to fit the scenario of medicalization—Gutting mentions shyness, restlessness, and anxiety—the 19th century provides us with an example similar to contemporary depression that should give us pause: nervousness. In 1991, the late historian Janet Oppenheim7 published a wonderfully detailed and nuanced history of the phenomena of nervous breakdowns, neurasthenia, and other nervous maladies in Victorian England. The book is noteworthy for a number of reasons, but especially for her insistence on taking seriously the complaints of those afflicted. Even if we agree with historian Edward Shorter8 and consider the 19th century habit of applying the label of “nervousness” to a broad array of personal difficulties to be nothing short of “a massive duplicity, a century-long deception of the public,” Oppenheim believed that underlying these problems was genuine human suffering.
So, too, does Shorter. From his perspective, the term “nervousness” was applied to mental illnesses even by medical professionals in the 19th century because of the stigma associated with insanity and its treatment. “For patients,” he tells us, “this camouflage presented an opportunity to escape the opprobrium of madness and the implications of hereditary illness and degeneration.”8 As a result, however, it opened up the treatment of various kinds of emotional and interpersonal problems to a wider range of healers beyond physicians. Thus, if Shorter’s description of events is correct, we have a prominent example of psychiatrists themselves actually helping to demedicalize affective disorders. So the story of psychiatry is not only one of inexorable medicalization.
There is another reason to question applying the term “medicalization” too liberally, one suggested by Oppenheim.7 As she points out, 19th-century psychiatrists and neurologists time and again proved to be tied tenaciously to the social values and assumptions of their time and place. There were gender stereotypes that proved stubbornly impermeable to factual contradiction. Since middle-class men were supposed to be rational, resolute, and ambitious, their nervous conditions were thought to be triggered by overexertion. Their female counterparts were assumed to be constitutionally mercurial, weak, and passive, leading clinicians to chalk up their ailments to evolutionary frailty.
At the same time, Victorians and Edwardians were drawn to describing nerves in economic terms and metaphors. “Nerve force” was treated as precious capital to be invested wisely. Men were warned against “taxing” or making a “sudden demand” of their “nervous resources” and “living beyond [their] physiological income.” Here, the language and concepts of commerce—familiar to the affluent bourgeoisie—helped shape clinical standards for living. In adopting these terms, physicians showed that they were hardly immune to middle-class pretensions and conventions.
All of this goes to show the extent to which 19th-century psychiatry and neurology remained open to the influences of the wider society at large. “Nervousness” may well have provided physicians a way to medicalize certain forms of mundane behavior and feeling. But do we not also have to concede that medicine itself was also being—for lack of a better term—societalized at the very same time? The process was a 2-way street. And if we accept that medicine and the rest of society has in fact reciprocally and constantly influenced one another, do we not have to adjust our understanding of medicalization accordingly?
This is not to say we need to dispense with the characterization. The example of 19th-century nervousness should press us, however, to acknowledge that no matter how we might define and assess it, the relationship between medicine, social values, and prevailing ideals for living is perhaps messier and more convoluted than it might seem at first glance.