Hero

Videos

Slideshows

Articles

Podcasts

Poll

 is a common term that describes individuals’ amazing capacity for resistance. Its sibling term, 

 (PTG), is less well known, however. PTG describes the positive psychological changes individuals will be able to notice in themselves in spite of a traumatic experience. Examples of PTG include statements such as, “Despite all the bad things that happened, I realize that I feel much more connected to other people now,” or “After what happened, I find myself focusing more on what is important to me and not what others want me to do.”

The resiliency concept has had many academic mothers and fathers, including Emmy Werner, PhD, (1929-2017; developmental psychologist at the University of California), and George Vaillant, MD, (born 1934; psychiatrist at Harvard University). The concept of PTG derives substantially from the work of psychologists Lawrence G. Calhoun, PhD, and Richard G. Tedeschi, PhD, from the University of North Carolina. Their cutting-edge research drew inspiration from ancient sources, including Greece and the Judeo-Christian Bible, as well as some of the teachings of Hinduism, Buddhism, and Islam that contain statements on the possibility of positive change through one’s own suffering.

Over the past 20 years, the main area of application for PTG and resiliency research has remained posttraumatic stress disorder (PTSD). As this disorder is globally prevalent and one that affects many US immigrants, it is important to assess the relevance of these concepts in a global context, especially for individuals from socially disadvantaged countries. Also important is that comorbidities are common in many patients with psychiatric disorders. Therefore, the area of application of PTG and resiliency research has expanded to include more mental disorders.

A significant question that has arisen from global research on the topic remains: How much resiliency and PTG can humans draw from themselves?

 has been reported in individuals who have experienced sudden loss of a loved one, chronic life-threatening medical conditions (eg, cancer, HIV infection), 

(eg, COVID-19), sexual assault/abuse, or refugee experiences.

 PTG may coexist with distress in the context of suffering and significant psychological struggles. The changes associated with PTG are experiential and powerful, encouraging survivors of adversity to spend time altering their cognition of the world and the self.

Resiliency is the trait-like capability of maintaining normal psychological functioning in the face of adversities or challenging life conditions. It is associated with the ability to interact flexibly with the environment and use personal resources effectively. Resiliency is relatively stable but not static because this capability may grow through cognitively reconstructing one’s understanding of adversities, or it may grow during the recovery process. Therefore, the growth or development of resiliency may be accompanied by PTG.

 seeks to promote well-being through assessment and interventions involving positive psychosocial characteristics in individuals who suffer from, or are at high risk of developing, mental or physical illnesses.

 It started within the last decade and is still in the process of establishing itself in the mental health field. Positive psychosocial intervention includes several components: resiliency-enhancing training, mindfulness-based coping strategies, the meaning-making process, and culture-bound holistic healing.

The assessed effectiveness of psychosocial intervention comes from results of clinical studies that have focused on the meaning-making process. The results of a 

 that used measurement-based interventions to identify and reframe the meaning of stressors for patients in the early stages of depression showed significant clinical improvement in those patients.

 The outcomes of clinical intervention programs emphasizing resiliency-based training have also provided evidence of positive psychosocial interventions. Programs that include individualized resiliency-based training have been found effective in improving clinical outcomes in key domains of social and occupational functioning for psychiatric patients in the 

Cultural Understanding of Psychiatric Resiliency

Culture is a a social constellation of components that include practices, competencies, ideas, symbols, values, norms, institutions, goals, constitutive rules, artifacts, and modifications of the physical environment. In clinical settings, culture involves contextual features, such as the economics, availability, and accessibility of services; patient variables, including differences in prevalence or manifestation of disorders, preference of alternative or informal services, health literacy, and adherence; and provider variables, such as referral bias and patient-clinician alliance. Cultural differences in clinical representations of mental disorders have been evident in studies involving cultural samples.

 and symptom presentation in outpatients in Asia, North America, and Europe indicated that patients from Vietnam, China, and other Asian regions endorsed significantly 

 than their European and North American counterparts, despite similar levels of depression symptom severity.

 In addition, cultural differences in understanding psychiatric stigma might influence whether US patients are viewed as more likely to endorse these symptoms than Chinese patients. For instance, in 

 who have psychiatric disorders, the Chinese sample scored lower than the US sample on positive symptoms such as hallucination, delusion, abstract thinking, stereotyping, anxiety, guilt, tension, and mannerisms.

Psychiatric resiliency refers to maintaining normal psychological functioning while responding to adversities that are related to psychiatric disorders. The inverse correlations are found between resiliency and the severity of psychiatric disorders, such as 

 Individuals with higher levels of symptom severity are more likely to demonstrate lower levels of resiliency. While individuals with less resiliency may possibly experience positive changes in the aftermath of their adverse experiences, 

 are nonetheless associated with higher levels of persistence and self-directedness in patients with chronic psychiatric illness.

 According to the Cloninger model, both environment (ie, character dimensions) and genetic endowment (ie, temperament dimensions) 

Cultural factors may affect resiliency through genetics and environment. In terms of genetics, culture may contribute to, or interact with, individuals’ self-identifying process through biological characteristics (eg, skin color, eye color, or facial features associated with race), behavioral phenotype (eg, eye movement deficits in schizophrenia), and the way they perceive adversities related to psychiatric disorders.

Environmentally, culture may shape resiliency by influencing human developmental processes and behavioral patterns through religion, education, and other physical circumstances. Research indicates that 

 the relation between resiliency and psychiatric disorders such as PTSD.

As one of the most important components of culture, religion may affect one’s comprehension of the world and the self (

). Religious contexts and spiritual appraisals of traumatic events have a robust relationship with posttraumatic outcomes, including PTG. The trauma recovery process involves rebuilding an assumptive world. Religion provides a meaning-making framework to process traumatic experiences and its related distress, as has been evidenced by different cultural studies. For example, results of 

 demonstrating PTG after experiencing a traumatic event indicated that religion had a positive effect on their coping.

 Many Asian cultures are not anchored in one particular religion; instead, spirituality in such cultures might be better understood from an existential perspective. Thus, spirituality may be represented in a manner related to resilient behavior and infused within a general approach to life in those cultures.

The Meaning and Implications of Resiliency

Preventive psychiatry aims to promote health and to protect individuals from developing mental disorders through early diagnosis, effective treatment, disability limitation, and rehabilitation. 

 have been found to reduce symptoms in some mental illnesses, including depression, psychosis, anxiety, and conduct disorders.

 The use of positive psychosocial intervention to prevent mental disorders and alleviate possible negative outcomes is part of the resiliency-enhancing process.

When we as professionals acknowledge patients’ ability to recover and grow, they feel more understood despite their often ongoing state of suffering. Interventions involving resiliency-enhancing and PTG-recognizing processes may benefit not only patients, but also health care workers and caregivers.

is an assistant professor of psychology in the Division of Social & Behavioral Science at Elmira College.

is a professor and head of division for the Department of Psychology, Psychopathology, and Clinical Intervention at the University of Zurich.

1. Weiss T, Berger R, eds. Posttraumatic growth around the globe: research findings and practice implications. In: Weiss T, Berger R, eds. 

Posttraumatic Growth and Culturally Competent Practice: Lessons Learned From Around the Globe

2. Tedeschi RG, Calhoun L. Posttraumatic growth: a new perspective on psychotraumatology. 

https://www.psychiatrictimes.com/view/posttraumatic-growth-new-perspective-psychotraumatology

Prevalence of posttraumatic stress disorder after infectious disease pandemics in the twenty-first century, including COVID-19: a meta-analysis and systematic review

4. Jeste DV, Palmer BW, Rettew DC, Boardman S. 

The Reliable Change Index (RCI) of the WHO-5 in primary prevention of mental disorders. A measurement-based pilot study in positive psychiatry

6. Kane JM, Robinson DG, Schooler NR, et al. 

Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program

7. Gry Secher R, Rygaard Hjorthøj C, Austin SF, et al. 

Ten-year follow-up of the OPUS specialized early intervention trial for patients with a first episode of psychosis

8. Gafoor R, Nitsch D, McCrone P, et al. 

Effect of early intervention on 5-year outcome in non-affective psychosis

Integrated treatment vs. treatment-as-usual for recent onset schizophrenia; 12 year follow-up on a randomized controlled trial

10. Roe D, Mashiach EM, Garber Epstein P, et al. 

Implementation of navigate for first episode psychosis in Israel: Clients’ characteristics, program utilization and ratings of change

The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America?

12. Dreher A, Hahn E, Diefenbacher A, et al. 

Cultural differences in symptom representation for depression and somatization measured by the PHQ between Vietnamese and German psychiatric outpatients

13. Aggarwal NK, Zhang XY, Stefanovics E, et al. 

Rater evaluations for psychiatric instruments and cultural differences: the positive and negative syndrome scale in China and the United States

Presentation and management of anxiety in individuals with acute symptomatic or asymptomatic COVID-19 infection, and in the post-COVID-19 recovery phase

15. Verdolini N, Amoretti S, Montejo L, et al. 

Resilience and mental health during the COVID-19 pandemic

An exploration of the relationship between culture and resilience capacity in trauma survivors

17. Darling Rasmussen P, Bilenberg N, Kirubakaran R, Storebø OJ. 

Mapping factors facilitating resilience in mothers – potential clinical relevance for children with ADHD

When kindness falls apart: the disrupting effect of dependency, perfectionism, and narcissism in adjusting to cancer

19. Acar Sivri G, Ezgi Ünal F, Güleç H. 

Resilience and personality in psychiatric inpatients

Psychiatry and Clinical Psychopharmacology

20. Cloninger CR, Svrakic DM, Przybeck TR. 

A psychobiological model of temperament and character

Cultural variations in resilience capacity and posttraumatic stress: a tri-cultural comparison

Trauma and children: exploring posttraumatic growth among school children impacted by armed conflict in Kashmir

23. Trivedi JK, Tripathi A, Dhanasekaran S, Moussaoui D.

 Preventive psychiatry: concept appraisal and future directions

Acknowledging a patient's ability to grow and recover may help them feel more understood despite ongoing suffering. 

Resiliency and Posttraumatic Growth: Cultural Implications for Psychiatrists

Laughter Therapy: Good Medicine to Make Your Heart Glad

Psychiatry Comic: Issues 

Telepsychiatry makes it easier for psychiatrists to treat patients by eliminating the need for either party to travel, with services provided from the safety and comfort of the psychiatrist’s home.

behind me, circled the rose garden sundial,

has been writing a poem about his experience of being a doctor every month for the past 23 years in 

 in a column called “Poetry of the Times.” He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts.

Two Crises I Didn’t Train For

Psychiatry Comic: Gray Matters

Susan J. Noonan, MD, MPH discusses cultural differences in health care. 

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

mental health and wellness virtual coaching practice, opening in July 2021, known as Noonan Wellness Coaching,and can be confidentially reached through her website at 

How can you increase sensitivity and confidence in working with a patient who has a different cultural background? 

3 Sources of Cultural Differences in Health Care

by Richard M. Berlin, MD; DOS Madres Press, 2021

Poetry can be dangerous. Plato knew the potentially subversive power of poetry and banned poets from his authoritarian utopia, the 

. With the exception of some poetry that extolled the state, Plato feared that poetry would “

corrupt youth and incite the passions instead of the faculties of reason

 Sigmund Freud—whose theories of infantile sexuality were themselves viewed as subversive by Victorian society—appreciated the power and psychological depth of poetry, famously writing, “Everywhere I go, I find that a poet has been there before me.” Indeed, this is the epigram that begins Richard M. Berlin, MD’s latest collection of poems, aptly titled 

 readers know Dr Berlin’s work from his monthly “Poetry of the Times” columns, which have been an enlivening feature of this publication since 1997. As a friend and colleague of Dr Berlin, and as a contributor to 

 since forever, I have been privileged to witness the evolution of his poetry over nearly a quarter century. Rich is widely regarded as one of the foremost physician-poets writing today, and has been the recipient of several awards, including the 2010 John Ciardi Prize in Poetry for his collection 

. His latest collection represents a worthy addition to his body of work—and, given Dr Berlin’s many medically-situated poems, the word 

Dr Berlin’s world of medicine is no place for starry-eyed idealists or worshippers at the shrine of Doctor God. If there is one feature that runs like a dark thread through Berlin’s poetry, it is his own doubts, fallibility, and perceived weaknesses. In his poem, “Confessions/Prayer,” he writes of “…an altar where I worship and pray / For mercy for all my failings;” and “how I hide behind my white coat’s / illusion of purity and perfection…” He prays “…to remember the healer / I yearned to become when I started / my studies…” There is, indeed, a kind of lamentation that runs through this collection of poems. To be sure, Dr Berlin’s medical vocation gives him a sense of deep pride and personal satisfaction, but also a wistful sense of what might have been. He feels drawn to the wider life beyond medical care. In “Daydreaming,” Berlin writes, “It’s hard to listen to patients / when songbirds sing outside / my open window and laughter / drifts up from families strolling / the shop-lined street.”

And, not surprisingly, there are complaints that will strike a chord with many practicing physicians: the endless battles with “the insurance mob…demanding records of patients’ private confessions”; the insurance company reviewer “who always wins”; and the ambiguities of psychiatric diagnosis (“all the old Borderlines and angry / adolescents melted down to Bipolar/slush.”).

What becomes of old Freud in Dr Berlin’s hands? The striking cover of the book shows a leather-upholstered couch floating in a swirling sea of brown-toned fabric. The dream-like image seems quite fitting for a book titled, 

. In the 3 linked poems of the same title, Berlin takes us into the many-layered world of the father of psychoanalysis, from his “twelve years deep into coca”; to the odor of the cigars Freud ceaselessly smoked; to his hiking through the Dolomites with his young daughter, Anna. 

Of course, Richard Berlin the man is more than Berlin the physician. He is also a husband, father, and sometime jokester. His poem “Sleeping Daughter” strikes the poignant chords that epitomize a father’s love for his daughter, “…desperate to protect her any way I can.” I recall here one of the formative poems of my own development as a poet: W.D. Snodgrass’s, “

,” and its epigram drawn from Irish legend: “…an only daughter is the needle of the heart.”

 In “Psychiatrist Baseball Cards,” Dr Berlin allows himself and his colleagues a bit of good-natured fun: “So take heart, dear colleague, misses / and swings are part of The Show.” Finally, Dr Berlin provides the reader a few pages of helpful notes that explain some of the less familiar medical and biographical terms that appear in the poems.

I suspect that for his frankness, honesty, and humor, Rich Berlin would have been among the poets banned from Plato’s 

. Plato’s loss, our gain. I believe that 

 will ennoble the physician’s calling and deepen both the medical and nonmedical reader’s perspective on our profession—even as Dr Berlin casts a cold eye on some of our collective shortcomings.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of

. Poetry Foundation. Accessed June 30, 2021. 

https://www.poetryfoundation.org/articles/69373/from-the-republic

2. Snodgrass WD. Heart’s needle. Poetry Foundation. Accessed June 30, 2021. 

https://www.poetryfoundation.org/poems/42794/hearts-needle

Frankness, honesty, and humor make this doctor’s poetry collection special.

Freud on My Couch

As we celebrate freedom in the land that prides itself on the tenants of life, liberty, and pursuit of happiness, I harken back to Frederick Douglass’s words, “I must mourn.” I would invite us to ponder the following questions: What does independence look like in a country in which the caste system flourishes? Are communities truly free from a crown decorated with enslavement in the forms of health disparities? 

Here is some food for thought in the form of a haiku:

 is clinical assistant professor at the University of South Carolina School of Medicine-Greenville and medical director & division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health-Upstate. He currently serves on the APA Task Force to Address Structural Racism Throughout Psychiatry as well as the Diversity & Inclusion Section Editor and Advisory Board member for 

As much as it is important to honor our country, it is also important to honor its ideals and continue the pursuit for such—for everyone. 

Independence Day Thoughts From a Psychiatrist 

is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned degrees in history from Wesleyan (BA), Stanford (MA), and Johns Hopkins University (PhD); he also studied psychiatric epidemiology at Columbia University. He is the author of

 Imperial Bedlam: Institutions of Madness and Colonialism in Southwest Nigeria 

 Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy 

 The Empire of Depression: A New History 

(Polity Books; 2020). His articles have appeared in journals including the

 Journal of the History of Medicine and Allied Sciences, Harvard Review of Psychiatry, Bulletin of the History of Medicine

Dr Sadowsky is a leading historian of psychiatry, and one I am proud to call him my teacher. As a psychiatry resident, I attended his lectures on history of psychiatry as part of our residency didactics and benefitted greatly from them. Sadowsky was 

 in 2017 by Greg Eghigian, PhD, about his book, 

Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy

, an interview that is well worth revisiting. The present interview is about his new book 

. I admire Sadowsky for his ability to tackle complex and controversial issues with scholarly rigor and fair-minded appraisal, and I am delighted to have him participate in this series.

: I suppose some folks, on hearing the title of your new book, may reflexively think, “What…another book about depression? Don’t we have enough of those already?” In your opinion, why was a new history of depression needed?

: Interestingly, not many of the books about depression are histories. Take 

The Noonday Demon: An Atlas of Depression 

 I think it is great, but it has only a single chapter on history, and it is a brief account. In addition, with a few exceptions, most of the history books are focused on antidepressants, but many other treatments have important histories—psychodynamic psychotherapy, cognitive behavioral therapy (CBT), electroconvulsive therapy (ECT), and the many approaches that were taken prior to the 20th century, for example.

A couple of long, detailed histories of depression barely mention ECT. This is weird. I know 

—my book about ECT is also about that controversy. However, whatever you think about ECT, many psychiatrists consider it among the best treatments psychiatry has for serious affective disorder. Imagine for a moment a medical historian in another specialty writing a long history of a particular ailment, and then only briefly noting a treatment many doctors say is among the most effective! Previous histories of depression have also been a bit weak on psychoanalysis, which is a strong interest of mine.

Little existing historiography of depression focused on patient experiences and self-representations. This is not an easy area to research, because a lot of depression treatment takes place in private office practice, a confidential setting, and documentation is not really publicly available. I would have liked to do more, but I hope I pushed the field a little in that direction. I want to add immediately that some historical and other critical studies of psychiatry see patient voices as only a way to criticize psychiatry. It is important to document patient complaints, but some critics of psychiatry go to tortuous lengths to deny any therapeutic benefits. Honoring patient voices also means seeing that many feel helped by treatment.

I also wanted to draw attention to the politics of inequality. Like so many other illnesses, depression hits different populations to different extents. Solomon drew attention to this, but most of the historical work on depression restricts inquiry to the gender ratio, which is an important axis, but not the only one. Class, 

 status, for example, also matter for depression, and I hope future historians will develop this further.

Finally, I wanted to make the story more global, less focused entirely on the West, and especially the United States, although I do give the United States a lot of attention. Anthropologists and global mental health workers have looked at the wider world, but historians really have not done so for depression. I would like to have gone further here, too, and I hope others will.

: What I love about your book is that it does not settle for easy answers. It embraces the uncertainty, ambiguity, contradictions, and flux inherent in the very subject matter. One of the difficulties with studying depression is it’s a fluid entity, with variations across both time and space. Is depression the same today as it was in the 17th century when Robert Burton wrote 

? Is depression the same thing in the United States and, say, Nigeria? These are obviously thorny issues. Can you elaborate on the approach you take to address this? How can we tell a coherent history of something if we are having a hard time pinning down what that something is?

: The various illness categories—or, as it may be in some contexts, conceptions that are not illness categories—are already included in a long-running discussion of the comparability of diagnostic categories and sickness experience across time and space. The discussion is a story itself.

Most of the illness states I compare have a core feature, which is excessive sadness or blue mood, in whatever that particular context considers excessive. But some definitions of depressive illness consider this a common, but not necessary, feature for diagnosis. As you know, DSM-5 does not require depressed mood as a necessary criterion for major depressive disorder (MDD), provided there is loss of interest and 4 other symptoms. I draw (lightly) on the concept of family resemblances Ludwig Wittgenstein, PhD: Things do not need precise overlaps to have similarities that justify 

 For all the imperfections of the DSM, I think if you look at the menu of symptoms for MDD, they do form a constellation of related signs of suffering that have been clumped together in disparate contexts.

Overemphasizing cultural differences has its own risks. I show in chapter 1 the idea that African societies had little or no depression had roots in some frankly racist ideas. Universalizing labels can be a form of cultural imperialism, but overinsistence on difference forecloses possibilities for meaningful comparisons. And some who think depression is a purely modern or Western illness might be surprised at how many cultures, across time and space, have had some conception of excessive sadness as a malady.

Chiara Thuminger, PhD, is a great historian of madness with whom I am collaborating on a new project.

She has set forth 4 principles for comparisons 

1. The human mind is biological, a part of a shared evolutionary heritage, so you can expect some measure of universality.

2. The mind and mental life are not confined to the brain, but involve other parts of the body.

3. Mind and brain are situated in and shaped by culture, so universality will always be limited.

4. Every individual has an irreducible quality, uniqueness.

I think these are great principles to keep in mind.

: You are clearly dissatisfied with a lot of popular critiques of depression. You write, “One thing this book is not is a long lament on the overdiagnosis of depression, and the turning of life’s normal suffering into a medical problem.” Tell us more about your dissatisfaction with this line of criticism.

: Many people look at the high numbers of individuals with a depression diagnosis compared with previous times and take it as self-evident that we are overdiagnosing. It is not. Rising diagnosis rates is a valid reason for concern about overdiagnosis, but it is not proof. In 1950, much of psychiatry was concerned that we were underdiagnosing depression, so from that perspective, we may be finding a lot that we had been missing. We should at least consider the upside: More diagnosis means that more individuals who could use professional help are getting it.

As for medicating the normal pain of living, we should keep in mind that getting treatment for depression, whether in psychotherapy or with antidepressants, does not protect anyone from suffering, although one hopes it is reduced. Life remains hard. And many patients with depression welcome sadness as a relief from feelings of deadness or numbness inside.

In the book, I offer some defense of antidepressants against their most severe critics. But I also think we are probably overreliant on antidepressants. I think the benefits of psychotherapy, particularly long-term insight-oriented therapy, have become underrated in the antidepressant era.

Still, why some advocates of psychotherapy are so adamantly and categorically opposed to any medication use, or to any suggestion of a biological component to depression, is a mystery to me. I have read many hardline critiques of biological and pharmaceutical psychiatry that are focused on whether the evidence for efficacy is robust, or questioning the philosophical underpinnings of the enterprise, or worried about adverse effects, or indicting the pharmaceutical industry. The thoughtful challenges have reinforced my view that we are overreliant on drugs, at least for some populations. Other critiques have struck me as dogma masquerading as critique. But even the smartest of them have not convinced me that antidepressants are worthless, a claim several important voices have made.

The biology of depression is incompletely known, and much of it may remain permanently elusive. However, the idea that depression is purely psychological is, I think, implausible. Yet, so is the view that depression is purely biological. The dichotomy itself is the problem. Mark Solms, PhD, said that mind and brain are 2 ways of looking at the same thing. I find this more helpful. I do not understand how something could affect either the mind or the brain independently of the other. That is not a coherent idea.

I am getting away from your question a little, but it is an important point. Proponents of a life history emphasis in etiology sometimes take it as self-evident that if trauma or neglect is the cause, the better solution must be psychotherapeutic, as opposed to somatic. Psychotherapy might be the better treatment, but it is not self-evident just from the etiology. And the reverse: Individuals who lean toward more organic theories of etiology—genes, brain chemistry—sometimes take it as self-evident that the better solution must be something more physical, like a drug or ECT. Again, this could be true, but it is far from self-evident. In any event, I think monocausal approaches to etiology are misguided.

: You write at one point, “The growing interest in depression led more people, both professional and lay, to learn to label problems as depression, which was a growing idiom of distress before the advent of antidepressants . . . The medications, though, provided new incentives for multiple actors—pharmaceutical companies, doctors, patients, and patient’s families—to identify cases of depression.”

 I suspect you would have been writing a very different history of depression if antidepressant medications had not been developed, or if their use had continued to be severely restricted due to tolerability.

A curious thing, however, is that anxiety disorders are more common in the general community than depressive disorders, and antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are not just antidepressants but also antianxiety medications. We could perhaps imagine an alternative history in which anxiety was the idiom of distress, SSRIs had been marketed as antianxiety rather than antidepressant, and you would perhaps be writing a book about the empire of anxiety, and the continuous historical links between melancholia and anxiety! Is it merely an accident of history that we ended up in the age of depression rather than the age of anxiety?

: Cross-cultural study has shown that the separation of anxiety and depression is a convention of Western psychiatry (which is rapidly becoming a global or cosmopolitan psychiatry, with both good and bad effects). Many healing systems around the world assume anxiety and depression are aspects of a single thing. And even in the West, the separation is somewhat new, a Kraepelinian innovation.

You present an interesting counterhistory. However, I am not sure the trajectory has been solely drug-driven. When the monoamine oxidase inhibitors and tricyclics were developed, psychiatrists were looking for depression treatments, and they had been doing so for decades. That is partly why these drugs came to be called antidepressants.

One curious thing is that important anxiety medications and antidepressants were introduced around the same time, and yet from a broad cultural point of view, we had first an age of anxiety—the immediate postwar period—followed by an age of depression, which started sometime in the 1970s and became more visible in the 1980s. In what I consider the most speculative portion of my book, I try to understand those periods as possibly representing wider cultural moods, perhaps rooted in different forms of capitalism. As speculative as that section is, I included it because I thought it was worth thinking about.

: You don’t spend much time discussing the creation of MDD as a diagnosis in DSM-III. I wonder how different the future course of events would have been in the absence of such a diagnostic category. If you look at DSM-II, depression was fragmented across many different sections under many different diagnoses. In DSM-II, we had diagnoses such as involutional melancholia, manic-depressive illness, depressed type, psychotic depressive reaction, depressive neurosis, and neurasthenic neurosis. I suspect that this DSM-II organization of depression would not have been particularly conducive to the process of empire-building!

: That is a great question, and I could have given this change more attention in my discussion of the DSM. However, I wonder if the creation of the category (if not the precise name) of major depressive disorder was already in process before DSM-III, reflecting the growing research interest in depressive illness in the years preceding the revision of the manual.

: When I look back at the evolution of depression, a pair of developments in recent decades appear to me to be notable, although their historical significance is probably yet to be seen. The first is the notion of treatment-resistant depression (TRD). This has led to more aggressive pharmacotherapy, such as augmenting with atypical antipsychotics, and the relatively recently approved medication esketamine.

The second is that bipolar disorder has been steadily encroaching on the territory of depression, such that even in the absence of mania or hypomania, many psychiatrists classify the presentation as being on the bipolar spectrum. Just as the development of antidepressants led to an increase in the diagnoses of depression, development of medications for bipolar depression have led to an increase in the diagnoses of bipolar disorder. Any preliminary thoughts of these developments as a historian?

: It is, of course, awful that some depressions are so hard to treat. I am not a clinician, but I wonder if many of those that seem resistant to aggressive medication treatment might respond to intensive psychotherapy, which can be expensive, or to ECT, which has risks of adverse effects (risks which are, in my opinion, generally greater than the risks of antidepressants, although I think in some cases, the risks may be worth it).

As a historian, however, I would ask if the whole category of TRD does not actually represent some progress, since it implies the other kind. A 19th-century alienist could not do much about any severe depressions at all. Many of my colleagues in history of medicine, and especially history of psychiatry, get nervous at any hint of a progress narrative, but I do not mind saying I think we have a better repertoire of treatments for depressive illness now than we did in 1850. All the treatments have downsides, but that is true of medical treatments in general.

I am aware of the rise of bipolar diagnosis, but I have not followed it closely. From a practical point of view, of course, what matters about a label is matching the individual in pain to the best treatment possible, and that is a clinical question. My historian’s take is: The safest prediction is that changes in diagnostic fashions are going to keep happening, and they will not necessarily be driven by genuine scientific advance. The whole enterprise is not worthless, but we should not assume the present trend represents the final or best word. On this point, I do worry about progress narratives.

: In a very memorable passage of your most recent book, you compare history with psychoanalysis: “[P]atients are locked into repeatedly telling the same story about themselves— about their loneliness or their victimization, for example. The therapy helps patients see that they do not have to repeat the same story. They can tell new stories of their lives. History can have a similar role . . . We do not have to live the same story, time after time.”

 Later, in the epilogue, you again refer to history as a means of guarding against compulsive repetition. Can you summarize what history tells us we can do differently going forward when it comes to depression?

: I will name 2 things. First, we do not need to keep having the same arguments about whether depression is fundamentally biological, or really the result of trauma in life, or the result of social forces. I fear that we will continue to do just that, because of the tenacity with which some individuals hold to the insistence that we must choose. It is my hope that by showing historically how insistence on a single approach leads to dead ends, we might be liberated from it. In the epilogue, I used the image of a quarreling couple, stuck in the same fights for decades on end. A good marriage counselor might be able to remind each partner that the other has things to offer.

I also hope we might be liberated from the cycle of hype and disappointment about new treatments. Most of the major treatments for depression over the last century (psychoanalysis, ECT, CBT, and antidepressants) have been overemphasized by some zealous proponents. Then disappointment (dare I say, depression?) comes when the harms or limitations of the treatments become clear. In turn, we rush to condemn the old treatment as worthless and latch on to something new, which is thought to lack the flaws of the earlier ones. But the old treatments still had something to offer, and the new ones prove to have flaws, although we may not see them right away.

New treatments are going to come, as they should. When they do, let us try not to overdo the hype, the radical rejection of the old ones, or the disappointment in the new that follows. In addition to helping patients overcome repetitions, psychotherapy can help patients to see individuals in and things in their complexity. Sometimes we, as professionals or as whole societies, can act like an individual searching for love, and finding partners we initially idealize, only to come to despise them when they inevitably disappoint us. We would do better to tolerate ambiguity. I hope Empire of Depression might help to foster that toleration.

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

 is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned a PhD in history from Johns Hopkins University and also studied psychiatric epidemiology at Columbia University. He has authored numerous articles and books, most recently 

Dr Aftab and Dr Sadowsky have no relevant financial disclosures or conflicts of interest.

The Noonday Demon: An Atlas of Depression

A History of the Mind and Mental Health in Classical Greek Medical Thought

Is depression the same today as it was in the 17th century? Is it the same thing in Nigeria as it is in the United States? One of the foremost historians of psychiatry weighs in. 

Exploring the Evolution of Depression

Memorial Day emboldens us to remember the men and women who sacrificed their lives for our freedom. We thank them for their service. This day also represents the 100th anniversary of the Tulsa Massacre. I would like to honor the generations of Black foot soldiers whose carnage must not be forgotten.

Sometimes a few simple words help us remember important events.

Eulogy for Wall Street

For the most part, the field of psychiatry has looked at organized religions with suspicion, however, a majority of sacred texts have paid particular attention to emotional wellness and holistic health.

I have used my religion and my Muslim background as a grounding and healing tool for myself, my family, my small community, and for clients who requested to use God’s words (the Noble Quran) and the authentic teachings and traditions of Prophet Muhammad (peace be upon him) as part of our therapeutic relationship.

It is usually much easier to introduce religious themes with terminology like spirituality and tending to the soul. Youth in particular seem to have a difficult time reconciling the religious aspect of their personality with societal expectations. I have queried Muslim youth and their caregivers, but my understanding from Jewish and Christian friends and colleagues is that there are similar themes in all 3 monotheistic religions. However, most of the Muslim community’s negative feelings around 

Psychiatry and spirituality have many things in common, including family dynamics, self-care, emotional intelligence, trauma healing, and suicide prevention. 

Cultural Psychiatry