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Problems Implicit in the Cultural and Social Study of Depression

HORACIO FABREGA, JR., MD This paper reviews issues and questions that are tied to the study of psychiatric disease in relation to social systems. The specific focus is on the Western disease depression. The first part deals with problems arising when depression is examined in relation to culture. This part, which is largely analytical, points to problems inherent in the field of cultural psychiatry. The second part addresses problems involved in the study of depression in Western nations. Epidemiological questions as well as factors involving the influence of social factors in the onset, duration and manifestations of depression are given attention in the attempt to bring out fundamental dilemmas tied to the social study of psychiatric disease.

INTRODUCTION Social psychiatry represents an area of inquiry in which one finds diverse types of emphases. These can be divided, on the one hand, into pragmatic emphases, (as seen, for example, in community psychiatry) and on the other, into theoretical and empirical ones that touch on how the various psychiatric diseases are related to the social environment. In this paper we would like to address some facets of the latter tradition in social psychiatry. Briefly, we propose to examine the way in which psychiatric diseases have ordinarily been studied in relation to social systems and to give principal attention to the logic of such inquiries. The aim is to bring to light some problems tied to the cultural and social study of psychiatric disease. Insofar as attention will be given to traditional paradigms in social psychiatry, the paper may be described as analytic. It should be understood, however, that a consequence of such a form of analysis is
From the Departments of Psychiatry and Anthropology, Michigan State University, East Lansing, Mich. 48824. Received for publication October 18, 1973; revision received February 25, 1974.

often the achievement of a clearer perspective towards empirical investigations, which in turn may feed back on policy and programmatic questions. The above described logical analysis of psychiatric disease is by nature general and abstract. In order to make this endeavor more specific and tangible it will do well to focus on social factors of only one disease entity. In this regard, we have chosen to concentrate on depression. This disorder has played an important role in Western medical history since ancient times and, furthermore, is currently the object of much empirical research and discussion (1-6). Consequently, clarifying theoretical aspects of depression highlights controversies and ambiguities that have played an important role in the evolution of psychiatry and which in fact are still problematic even today. In addition, the changes associated with depression are such that they highlight important and also generic problems that are germane to fields of both medicine and social science. In short, examining theoretical aspects of the relation between depression and sociocultural systems not only involves dealing with long standing and essentially unsolved theoretical problems within psychiatry proper, but also addresses rather
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Copyright 1974 by the American Psychosomatic Society, Inc. Published by American Elsevier Publishing Company, Inc.
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fundamental questions about the relations between disease, medicine and society generally (7).

THE IDEA OF DISEASE AND THE IDEA OF PSYCHIATRIC DISEASE

From a logical standpoint, we can say that disease constitutes a person-centered undesirable deviation in the value or values of a cluster of related biological indicators. Disease indicators are deviations in special biologically relevant variables (eg, blood pressure, blood sugar, etc), and clusters of these represent (by definition) a disease. Since deviations are defined in terms of normative ranges that are empirically derived, diseases are strictly speaking not univeral entities, but instead, tied to specific spatiotemporal frames. Stated differently, man adapts to distinct ecological niches, and since normative ranges of the various biological variables are framed in terms of such ecologically based adjustments, it follows that disease (clusters of deviations in biological variables) are relative and population-based "entities." Psychiatric diseases are problematic precisely because their relevant indicators are rooted in or impinge directly upon social conduct (8). By and large, such things as x-ray shadows and/or the presence of protein in one's urine are neither reflected in social behavior nor do they reflect on a person's identity. Consequently, being told one has pneumonia or chronic glomerolorephritis is not, generally speaking, discrediting to the person. It is the direct link that psychiatric diseases have with social behavior that make for the special psychological and social problems that are created by psychiatric labeling. Stated differently, the fact that general-medical disease indicators are ordinarily divorced 378

from social behavior leads physicians and persons to use disease labels in such a fashion that they usually prove socially inconsequential; when these labels are psychiatric ones, however, they lead to social problems because the labels devolve from behavior and reflect upon one's identity. There are exceptions to this matter of disease labels, and psychiatry is of course not unique in this regard (9). Nevertheless, despite these considerationswhich essentially involve the social consequences of psychiatric labelingas logical entities, psychiatric diseases are formally analogous to other medical diseases.

PROBLEMS POSED BY THE CULTURAL STUDY OF DEPRESSION


The Problem of Defining Depression A reading of the psychiatric literature discloses that controversy and problems surround the definition of depression. This paper can be viewed as an attempt to shed some light on this controversy. We will suggest later that some logical and definitional problems take their form and content from ethnocentric assumptions; that is, that they stem from too strongly relying on criteria that are tied to our distinctive sociocultural frame of reference. In fact, although a great deal of research has been directed to cultural aspects of depression, we will indicate that much of this research, and especially the inferences that the research findings generate, are misdirected and contaminated by Western cultural biases. These biases, it is to be emphasized, obfuscate matters and retard the articulation of a perspective that could be more productive for the understanding of depression. In order to expose the nature of these biases, it will do well to initially handle "depression" as though it were a purely linguistic entity. In this

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light, we will for the moment ignore the various processes and manifestations that give "depression" its meaningie, we will neglect the semantic properties of this termand concentrate instead on more abstract or generic considerations (10-12). From such an abstract and essentially logical perspective we can say that "depression" is a term that signifies a set of related organismic processes that lead to, produce or are reflected in a set of negative changes or deviations in the way the organism functions (eg, physiologically, socially, psychologically, etc). Defined in this fashion "depression" is a term, much like any other medical term that signifies a disease state. The nature of the processes that define and constitute "depression" are left unspecified, and likewise the set of related deviations or dysfunctions that reflect these processes are not addressed in any specific manner. We may parenthetically note that from observations of ill persons in Western cultures, physicians and psychiatrists (who themselves are of this same culture) have singled out "emotional changes" as central manifestations of "depression." Moreover, of these types of changes, those that connote a sense of self-denigration, hopelessness and despair have been raised to the status of paradigmatic indicators of the disease. Other indicators of the disease signified "depression" (eg, physiologic, behavioral, cognitive, etc) are seen as both reflecting and elaborating upon the emotional ones. For expository purposes we may label those dysfunctions that constitute our Western interpretation or view of this entity Di, D^ Dn, keeping in mind that from a generic and formal standpoint the changes Aof this entity could be termed Di D2 D*, where: D = dysfunctions or deviations seen in "depression," W = characterizations of these dys-

functions based upon Western cultural symbols, and A = an abstract culture-free characterization. We can in this regard introduce the term Dj, letting it signify dysfunctions that are distinctive of that which we label as "depression" in a mythical culture X. In thinking about "depression," it will prove instructive to isolate on semantical grounds four separate issues. Thefirst,we will stipulate, represents the underlying microleveled organismic processes that are characteristic of that which is labeled as "depression" (eg, neurochemical changes). The second one involves the macrolevel organismic changes that constitute the disfunctions that are characteristic of "depression" (eg, emotional changes, behavioral changes). For purposes of brevity, let us term these behavioral disfunctions. Earlier, one and two were referred to together as Df, with A standing for a culture-free characterization. Such disfunctions, then, are idealized and pure in the sense that we view them as not yet realized. From a certain standpoint, of course, this consideration is purely theoretical since what we designate as "depressions" can only exist in relation to a distinctive sociocultural frame. We nevertheless draw attention to this level of analysis for heuristic reasons. The relations between events and phenomena in one as compared to two above should not be seen as causal. For example, it often proves awkward to say that bodily changes cause emotions or behavior, or vice versa (13,14). Rather, the domains should be seen as logically independent and relations between them conceived of as mappings or transformations. Thus, a functional relationship may be said to exist across the domains though the nature of this function is unspecified. The third issue to be taken note of in our semantical analysis of "depression"
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involves the behavioral dysfunctions signified by the term as these are expressed in a particular culture. In our culture, for example, these are represented by crying, feeling listless, reporting and otherwise showing anergia, etc. We earlier labeled these Di. Distinctive and culturally marked behaviors, then, are what we have in mind here. The fourth and last consideration that relates intimately to the third involves the meaning that is given in a particular culture to the dysfunctions of "depression" as these are expressed in the culture (eg, terms such as "sadness," "helplessness," "weakness," etc, may be used). Item four, which is purely symbolic, is thus represented by the labels and terms that give meaning to those behavioral dysfunctions that constitute "depression" in a given culture. These matters are depicted in Fig. 1. It needs to be emphasized here that from a certain philosophic

perspective, behavioral changes that one observes have the meaning and significance that are contained in the very labels used to describe them (15). Stated differently, behaviors have no meaning outside the very language we use in description. This is the same as saying, for example, that at the level of human awareness, biologic processes such as raw sensations cannot be identified. What are identified instead are perceptions or private representations, and these already contain a theoretical or conceptual element reflected in the very terms we use to signify them. It is for this reason that in an empirical sense, item three can be distinguished from item four only with difficulty, if at all. In the light of issues discussed above, we may point to four connecting links that need to be taken into account in understanding that which we term "depres-

Physical Environment Social and Cultural Genetic Complexes

Organismic Processes that take place within an individual that are distinctive of Depression (D R ) (Defining characteristics of Depression?)

Behavi ora1 Changes

that reflect processes d atin cti ve of j Depres sio i (pfin inp n tstics of Depression?)

How the Organismic t Depression, as xpreased in a Cultur. haracterized in the distinctive of Deexpregsed in a given Culture (D*,

Fig. 1

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sion." These are also labeled in Fig. 1. Connecting link (a) involves how the changes of "depression" are produced (ie, "causal factors" and processes). Linkage (b) how the microlevel processes (eg, neurochemical changes) become transformed into the macrolevel processes (eg, idealized behavior dysfunctions that are distinctive of "depression"). Linkage (c) signifies the process by which such potential behavioral dysfunctions get encoded into a culturally specific form. Finally, linkage (d) signifies the relations that obtain between culturally structured phenomena (eg, symbolic behaviors) and culturally specific symbols (eg, linguistic terms). Is Depression Found in All Cultures? (The Problem of Universality) Empiricai Findings. An enduring preoccupation of persons who work in the fields of social and cultural psychiatry centers around the question of whether the disease depression "exists" in other cultures. The prevalence of depression in Africa may be used as an illustration of the problems just discussed (16). Although there are exceptions, the literature indicates that during the Colonial Era (1890-1956) instances of depression (of a psychotic nature) were either absent or rare, less intense and shorter in duration if present, rarely included self-castigation on the part of the diagnosed person and, lastly, seemed to rarely involve suicide. These generalizations are based on data drawn from mental hospitals. Various reasons have been offered for these alleged findings: One set of these involves the validity of the findings; for example, that hospitalized patients constitute a poor and biased sample, that what an external observer would judge as an instance of de-

pression is not differentiated in any significantly medical way by Africans and hence cannot be brought to the attention of medical personnel, etc. Another set of reasons for the alleged absence of depression in Africa assumes the validity of the reports and involves psychosocial factors believed to play a role in the etiology of depression: for example, that the extended family and funerary rules "protect" persons who are mourning over object loss; that Africans make extensive .use of the defense mechanism projection and consequently cannot develop guilt; that among Africans a clan as opposed to personal superego prevails and that such a form of psychosocial control also eliminates a necessary condition for depressive symptomatology, etc. Reports suggest that during the era of Independence (1957-onwards) instances of depression were not only not rare but actually common. The reasons for the increment in the prevalence of depression are believed to be that the newer observations took place in so-called "open" hospital settings as well as in indigenous treatment centers, and that researchers were now relying on newer concepts of depression that included somatic preoccupations as indicators of the disease. As stated earlier, persons showing evidence of depression are often not judged as ill by their co-members, but if they are, they are more likely to be treated in indigenous centers where psychiatrists had now turned for observations. Furthermore, researchers were now using the label depression for states that earlier would have been classified as "neurasthenia" or "hypochondriasis." Given these considerations (equivocal findings and conflicting methods of procedure) and the absence of suitable field epidemiological studies, one is forced to conclude that we do not know whether in fact depression
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is as prevalent in Africa as it is in Western nations. Even when depression is studied in settings that share a common language and set of traditions the problem of comparative epidemiology of this disease is a perplexing one and seen to involve a number of theoretical issues. Thus, a long standing finding in studies that compare rates of hospitalization for psychiatric disease in England and in the United States has been the differential rates observed for manic-depressive psychosis and schizophrenia. Consistently, investigators have uncovered higher rates for manicdepressive psychosis and lower ones for schizophrenia in England (17). For reasons outlined elsewhere in this paper, hospital rate differentials are difficult to interpret. One way of explaining them is in terms of differences in the behavior of psychiatrists as opposed to those of the patients. The rate differential, in other words, could be due to differences in the way British and U.S. psychiatrists construe and use concepts such as "schizophrenia" and "manic-depressive." The U.S./U.K. Diagnostic Project was addressed in part to answer just this type of question (17). It involved the training of a small group of project psychiatrists in the use of a standard interviewthe present State Examination developed by John Wing and his colleagues in Londonand involved the evaluation and diagnosis by these psychiatrists of a group of recently hospitalized patients in New York and another in London (18). In each locality, the diagnoses rendered by the Project psychiatrists on a group of patients were systematically compared with the diagnoses rendered by the regular hospital psychiatrists on the same group of patients. Hospital diagnostic profiles conformed to expectations, with British personnel rendering a higher frequency of manic-depressive and a low382

er one of schizophrenia when compared to the American. The Project psychiatrists, on the other hand, produced diagnostic profiles in each of the two settings that were in closer agreement, although acrossnation differences of a smaller sort still prevailed, suggesting to the researchers that actual patient differences may have existed. At any rate, the elimination of significant amounts of across-nation variation indicates that much of the difference one observes in international comparisons may stem from differences in the way the corresponding diseases are construed by the psychiatrists. Thus, when relatively standard instruments are used by a homogeneous and rigorously trained group of psychiatrists, the actual diagnoses rendered on patients from allegedly contrasting populations tend to more closely resemble each other (20,21). Another approach to evaluating this same possibility that cross-national differences in rates of hospitalized patients stem from behavioral differences of psychiatrists involved the audio-visual taping of patient interviews and the subsequent use of the tapes as data that psychiatrists in the U.S. and U.K. used to render diagnoses. In one of diese studies, examining psychiatrists were furnished additional background data on the patients. Despite the fact that U.S. and U.K. psychiatrists were evaluating the "same" patients, as it were, across-nation differences in proportion of depression still prevailed and conformed to expectations (22). The other study, which used only the audio-visual tapes and did not furnish psychiatrists background information, also produced significant across-nation differences in use of psychotic diagnostic categories as anticipated. This again indicated basic differences in concept meaning and suggested to the investigators that serious restraint be placed on the interpretation of

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differences in psychiatric disease rates cross-culturally (23). Katz has conducted a similar series of studies and concluded that perhaps basic differences in the way psychiatrists perceive and interpret behavior itself (in addition to differences in the way psychiatric concepts are used) may be a factor explaining cross-national differences in psychiatric disease rates (24). It goes without saying, of course, that rate differences such as these must ultimately be traced to social and cultural differences in the way the psychiatrists are enculturated and socialized, both as members of their respective social units and professional groups. Comment. How may we characterize these approaches to the study of "depression" in other cultures? We can say that researchers are using as a model of "depression" those behavioral changes that we in Western-influenced cultures believe are paradigmatic indicators of "depression." In other words, they are using the various D as the bases for determining whether "depressions" exist in other cultures. If all of the organismic changes that we have come to associate with "depression" are shown to be present in a member of a particular culture (eg, an individual with sadness, guilt, anergia, etc), then it is said that "depression" exists in that culture. When only some of these changes are observed, or when the changes observed are believed to be analogous (ie, similar, culturally "equivalent") to those found in Western cultures, then it is said that "depression" assumes a somewhat altered form. If the changes observed in a given individual (who may or may not be judged as sick in the culture) cannot be equated with those changes we associate with "depression," then he is said not to have "depression." And finally, if no individuals are ever found who show the Western changes or indicators of "depres-

sion," then "depression" is said not to exist in that culture. In short, it should be obvious that definitions and essential features characterizing what might be called the "Western version of depression" are taken as the true or real indications of "depression"; using these as a yardstick, attempts are made to diagnose "depression" in other cultures. This is what was meant when it was said earlier that ethnocentric assumptions (ie, biases) underlie the cross-cultural study of psychiatric disease. Given the way in which psychiatry has evolved, we can with the advantages of hindsight understand and explain how it was that these biases came to underlie the study of depression. Since ancient times, the disease depression (then called melancholia) has assumed a more or less distinctive (Western) form that involved emotional and behavioral changes of a type we now view as "classic" or pathognomonic (1,2). Sadness, despair, helplessness and bodily preoccupations of various sorts, in other words, have consistently been a part of what depression, ie, melancholia, meant. It is no surprise, then, that these types of changes are still seen today as indicators of depression, a disease codified by Kraepelin on the model provided him by ancients. The behavioral dysfunctions that we have come to view as classic of depression have maintained a measure of specificity and interconnection in our Western culture over the years. We may have brought greater refinement to the descriptions of these changes, but that they partake of the same general form and semantic markings cannot be debated. We should emphasize that since ancient times, depression (or melancholia) has assumed a characterization and interpretation that wholistically oriented psychiatrists now claim is exemplary of this disease; namely, that of judging it a psycho383

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biological entity. Behavioral changes that we of Western culture associate with both of the separate domains of mind and body have consistently been associated with and been seen as typical of depression. We have only to be reminded that the term melancholia literally means black bile; that its meaning is tied to humoral notions used to explain bodily and temperamental differences and that such humoral notions in time gave way to a theory of personality and of disease. An ancient version of our modern and refined unified view of disease is bound together with the notions of the various humors, and depression, ie, melancholia has always been linked in a literal sense with such ideas (25). A research question that inevitably arises can be phrased as follows: what is the nature of the linkage that exists between, on the one hand, those micro and macro organismic changes that we have identified with "depression" (ie, roughly DA)and the behavioral dysfunctions that we of Western-influenced cultures have come to judge as pathognomonic of "depression" (ie.Dw). Stated differently, if that which is signified by the term "depression" is a psychobiologic entity, then why and how are the underlying psychobiologic changes of "depression" transformed into the form that we see and recognize in our everyday clinical work? Similarly, we may ask how do the psychobiologic changes of "depression" get transformed into other cultural guises (ie, Df) ? Why, for example, do the organismic changes (ie, the Df) of "depression" lead to sadness-despair in our culture? What might these same changes lead to or produce in other cultures? It should be clear that in terms of the perspective we have adopted here, this amounts to inquiring into the function and mechanism of
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elemental symbolic categories and premises that structure behavior, feeling, cognition, etc, in individualsthe very roots of where biology and culture meet. One assumes, in other words, that man considered biologically (ie, chemically, neurophysiologically, anatomically, etc) is the same everywhere, and that alterations in his biology are likewise similar, ie, involve identical mechanisms and processes. However, how these biological changes become transformed into various specific behaviors and why they assume the particular expression that they do in distinctive cultures is dependent on fundamental symbolic categories that structure and encode behavior. Let us elaborate on this point. In Western culture, as we have said, sadness and despair are emotional tones and behavioral dispositions that are linked with and come to express those organismic changes that are distinctive of "depression." We have reason to believe that the underlying processes and units that lead to the encoding of these emotions in the human face are general universal attributes of man, and an implicit assumption appears to be that the emotional experience that signals these facial displays are also probably universal attributes of man, though this of course can never be proved (26). Stated succinctly, we assume that all members of the human species feel something akin to what we term sadness and despair, and moreover, express and recognize such moods in others by means of distinctive facial displays. However, how does this mood come to be associated with a particular behavioral constellation, and why is it that in our culture the resulting changes when persistent tend to be judged not only negatively but also as a disease? Is there in point of fact a universal mechanism that

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links the mood with the behavioral constellation in the first place? Is there also, as we tend to assume, something necessary about the connection between these mood-behavioral alterations and the underlying organismic changes (D;) that may be judged as the true significata of the term "depression"? Might these same underlying organismic changes be linked with other mood tones or behaviors in other cultures, or might no recognizable mood alteration be associated with the organismic changes of depression? Is the emotion we term despondency or sadness a necessary feature that is always or usually an outcome of D;? Are there culturally invariant behaviors that are always or usually an outcome of D'f ? We are led to entertain the possibility that the underlying organismic changes of "depression" (ie, the denning characteristics) may represent alterations in elemental biological mechanisms of man and the higher primates (27), perhaps disarticulated processes involving the conservation of energy as Engel has suggested (28). Persons socialized in various cultures must be presumed to express these changes in various ways. Why we of Western-influenced cultures show and feel sadness and despair under these circumstances may depend on basic symbolic calculi that structure and give meaning to our experience. They are, in short, our culturally specific way of reflecting such organismic changes. We must be prepared to find other culturally specific ways in which those elemental changes of "depression" could enacted. Thus, the question underlying empirical inquiries of "depression" in other cultures should not be: Can we find D D^- D^ in cul ture X? The question should rather be: What form will Di D2X- Dx take on in this culture? Or, stated differently: How

will the fundamental organismic changes that define "depression" be enacted in this culture? Are There Legitimate Questions to Pursue in Cultural Psychiatry? It may appear that adopting the position we have outlined above amounts to the elimination of the field of cross-cultural psychiatry. After all, if studying "depression" in other cultures using ethnocentric biases (ie, by searching only for specific dysfunctions associated with "depression" in Western-influenced cultures) is either fallacious or at least a crude approach, then how is one to go about this search? What procedure can be adopted when, it would appear, one literally does not know what one is looking for! First of all, it should be appreciated that on empirical grounds there is nothing wrong with studying "depression" crossculturally using the Western model as a yardstick. In a sense, clinicians of any discipline adopt this approach each time they evaluate any patient, and the procedure is the cornerstone of any inductive science. Using the Western analogue of "depression" as a guidelineas afirstapproximation, to be refined and modified allows the researcher an initial mode of exploration. It allows him to evaluate the extent to which the various D^preserve an identity cross-culturally, the extent to which they interrelate and coalesce with other D i and D* into discernible behavioral syndromes and by extension the reading or symbolic interpretation given to such syndromes in the cultureie, how they are judged, what interpretation is given to them, etc. However, rather than losing interest or discarding data when certain organismic dysfunctions or deviations (D7) appear in altered formor new ones pf) appear associated with the expected
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onesthe researcher should strive to accurately describe these phenomenologically and behaviorally. Rather than saying D; appears masked here, he should say perhaps a new set of D*obtain here, and these need to be accurately depicted. It is only by way of drawing on many of such cultural versions or models of "depression" that a fundamental understanding of what we have come to call the disease depression will be achieved. The rationale described above implies that cultural psychiatry should preserve both a descriptive and inductivist base. An extension of the rationale outlined can be visualized: cultural psychiatrists should aim to describe and explain the reasons for the prevalence of various behavioral syndromes. These syndromes should be seen as composed of behavioral deviations, and the syndromes should have a morphology such that they are patterned across individualsie, they should show cultural specifity. Whether such behavioral syndromes are judged as diseases by members of the culture should be in one sense irrelevant. Psychiatry as here defined, is the science that seeks to discover and explain the regularities in human behavioral deviations. Whether such syndromes constitute disease is purely a social and cultural matterthat is, this depends on native rules that assign meaning to the behavioral deviations. Medicine, it should be remembered, is also a social science in that it assigns the label disease to a set of selected behavioral regularities that are disvalued and that society and its members judge should be eliminated or corrected (7). It cannot be doubted, of course, that psychiatry profits to the extent that it can also explain why certain behavioral deviations or syndromes get assigned the label disease whereas others do
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not. In fact, insofar as psychiatry can also be defined as the branch of medicine that seeks to understand and treat psychiatric disease, it stands to reason that it must address those processes that attend the singling out of certain behavioral syndromes as disease, and especially the reasons for these essentially sociomedical considerations. In this regard, we should point out that few persons have addressed this issue in any intensive manner. It will no doubt be appreciated that what we are arguing for at this juncture is for a perspective towards the cultural study of "depression" that is essentially biocultural as opposed to only sociocultural. With regards to that which is signified by the term "depression," we should strive to articulate its defining characteristics in as near a culture-free language as possible. From the frame of reference adopted in this paper, this means that one should strive to uncover and systematize two interrelated aspects of "depression": on the one hand, interrelated neurochemical and neurophysiologic changes that in their totality underlie behavioral alterations that may show a measure of specificity across space and time; and on the other, the abstract and generic forms or moulds that set bounds on how these behavioral alterations are actually expressed in a culturally contextualized form. Both of these may be judged the significata of the term "depression." It is granted that these neurobiologic categories can only be equated (initially) with the Western behavioral version or model of "depression"; nevertheless, the fact that these neurobiologic processes might be articulated in a language frame that is uncoupled from social behavior means that cultural inquiries into the nature of "depression" are substantially

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aided (7). By means of successive approximations that involve working with both sociocultural and neurobiologic paradigms, it may be possible to achieve a comprehensive understanding of what the changes signified by "depression" mean. In the same vein, cultural explorations of "depression" need to be linked with the paradigms of human genetics, population biology and medical ecology generally. This means that older approaches characteristically associated with the fields of culture and personality and psychiatric anthropology need to be broadened so as to admit population and other biological considerations. A reading of the social science literature discloses that such a biocultural approach is being emphasized more arid more (29). Ultimately, explorations in cultural psychiatry will be concerned with identifying the mechanisms and processes by means of which basic neurobiologic happenings become translated into behaviors. This will involve describing, codifying and explaining the workings of the symbolic categories that are at the root of behavioral organization. These symbolic and most probably cognitive categories or maps are what structure, form and in essence establish behavioral regularities. It is these categories, moreover, that mediate between neurobiology and psychological and behavioral changes. What are the forms of these categories, how are they organized and how are they related to the other patterns, values, rules and institutional arrangements that make for cultural distinctiveness ? How and why are behavioral syndromes formed? And, given the existence of such behavioral syndromes, in which cultural groups are they viewed as disease? And, what factors or reasons might lead to the viewing of such syn-

dromes as diseases as opposed to something different? These and similar types of questions, in our estimation, articulate the proper locus of cultural psychiatry.
PROBLEMS POSED BY THE SOCIAL STUDY OF DEPRESSION IN WESTERN NATIONS

Here we examine theoretical problems that arise when social aspects of that which we view as the disease depression are studied in Western nations. We will not discuss differences in depressive symptomatology across ethnic groups since this involves considerations logically equivalent to those already reviewed. Despite the fact that depression will be dealt with generically and as though its identity and attributes were more or less unproblematic, we will see that definitional and other conceptual difficulties nevertheless arise that impinge on and can misdirect empirical inquiries. These difficulties need to be resolved so that investigations can generatefindingsthat will clarify the links that a psychiatric disease such as depression has with social happenings. Problems Associated with Epidemiologic Inquiries In studying the amount and distribution of a psychiatric disease such as depression, hospital statistics and comparable data from other mental health facilities have limited utility. In a "hard" sense, figures based on hospital statistics can be taken to reveal little but the clinicaladministrative policies of the particular facility in questiontheir diagnostic habits, as it were. Such figures have been used to make general and essentially imprecise
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inferences about the attitudes, habits and social conditions of the respective population groups. For example, given certain hospitalization rates, one may be led to infer that groups do or do not use hospitals, or that they are more likely than other groups to turn to hospitals. Alternatively, one can say that a particular group may or may not be more tolerant of deviant behaviors than another (ie, with hospitalization rates being taken as a measure of the exclusion of deviants) or, finally, that the group may have a different level or amount of psychiatric problems. These and, no doubt, other inferences can be drawn from epidemiologic studies that draw on hospital statistics. When combined with data from various sources and which has been collected under different conditions, hospi-il rates can be used to answer limited questions as Kramer has already indicated (17). It may be believed that field studies offer the solution to the problem of establishing meaningful rates or prevalence or incidence of a disease such as depression. However, given the nature of the theoretical and methodological problems surrounding psychiatric epidemiology, very little in the way of cogent and revealing generalizations can be drawn from field studies purporting to measure the prevalence and incidence of psychiatric disease. In psychiatry one finds fundamental conceptual problems regarding the definition and meaning of normality, psychopathology and disease. In a formal sense one would say that the "proper" domain of psychiatry is poorly bounded; elemental properties that unambiguously set phenomena apart as psychiatric as opposed to that of other service disciplines are lacking. At the same time, current methodological attempts to measure and establish "caseness" in such field studies
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untreated instances of the disease, as it werecan be faulted on so many accounts that results of these studies can only be used to draw but limited insights of a telling nature. Furthermore, conceptions of depression are currently in such a fluid state, and understandings of the nature of depressive disease(s) so variable, that little can be gained by reviewing in detail earlier studies that have employed differing and overlapping definitions regarding depression. (Issues discussed earlier are germane here.) Ideally, a social epidemiologic inquiry should begin with a clear analytic definition of a particular disease entity. This definition should in turn be operationalized by the development of indicator tests of the disease. In practice, this means that the uncovering of a particular set of indicators can be said to constitute necessary and sufficient conditions for inferring (ie, diagnosing) the disease in question. The measurement of the indicators of such a disease should be easily accomplished and subject to unambiguous interpretation. Studies employing such operational definitions of disease should be conducted using a bounded social group as a reference population. Field methods and survey analyses are called for, and a probability sample drawn from the community is evaluated so that both treated and nontreated instantiations of the disease in question can be unambiguously marked. Coincident with this, there should be a survey of the rosters of all in-patient and out-patient facilities that service the group so that treated instances of the disease can be verified and/or discovered (in the case of hospitalized patients). Private psychiatric and other medical practitioners should also be consulted. Questioning the latter becomes critically important in the case of depressive disease, since patients

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so diagnosed, it has been established, are frequently seen by general practitioners and internists. In general, social epidemiologic studies that meet these standards are not common, and conceptual and methodological problems involving how disease is to be marked contribute importantly to this state of affairs. As one may anticipate, social psychiatric epidemiologic studies that meet the above standards are rare. A number of field investigators have used a rather global definition of psychiatric caseness, namely, symptom scores derived from questionnaire responses (30,31). Although useful for certain purposes, such methods are of little value for those interested in evaluating a particular nosological entity. In these studies, subjects (ie, potential cases) are not interviewed by psychiatrists. Rather, protocols of interviews conducted by lay persons and social scientists are subsequently rated globally by psychiatrists. In the Leighton studies, symptoms were classified into syndromes and the APA manual was used descriptively for this purpose. Consequently, a degree of nosological specificity was maintained; however, it still was the case that rather general questions were used as the basis of generating data (32,33). Thus, although patients were classified as neurotic or psychotic, it is clear that no confidence (in a clinical sense) can be placed in this signification. More recent studies by Dohrenwend have brought to light some of the biases and deficiencies of these particular types of studies and raised questions about the validity of conclusions drawn from them (34). He has pointed to the differences in the way that ethnic groups respond to symptom questionnaires ("modes of expressing stress"), to the neglect of contextual factors in the evaluation of symptom responses and to

the fluctuating nature and predictive inaccuracy of such symptom responses. There are, to be sure, a number of rather basic problems associated with the use of such scores and these need to be discussed briefly. Symptom questionnaires that are typically used in field psychiatric epidemiologic studies include psychologic and psychophysiologic referents. Persons are asked whether they experience such conditions as sweaty palms, sadness and tiredness. What is obtained in such studies is a distribution of symptom scores and these scores are seen almost as linearly related to the issue of psychiatric disability and caseness. In some instances, ancillary information about person's social adjustment is included. By developing cutoff points using similar data obtained on known psychiatric patients, the investigator infers how many cases exist (and what are their degrees of disability) in his sample. The comparison group "patients," in terms of which cutoff points are framed, is usually heterogenous and includes various diagnostic types. This rationale for defining cases in field psychiatric studies harbors the following implicit assumptions: since psychiatric disorders are handled in terms of symptoms, they must all be of a similar behavior, psychologic or biologic type; psychiatric diseases all bear equally on a notion of psychiatric status or "patienthood," and furthermore can all be graded comparably in this regard and as to degree of associated disability; each instanciation of a disease can be placed unproblematically on a continuum of disability for that disease; and lastly any and all symptom scores (regardless of basis) can be evaluated similarly, which means that disease types and their associated continua of disability are fused. It hardly appears necessary to emphasize
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here that all of these assumptions are very questionable and conflict strongly with the classic nosologic view of psychiatric disease. These criticisms should thus not be seen as directed at the psychiatric epidemiologic approach per se, but rather at the tendency to uncautiously generalize about matters of psychiatric nosology using results from field epidemiologic studies wherein symptom levels constitute the key dependent variables. Recent studies of ethnic differences in depression bring into focus problems involving the epidemiology of this disease. This work was carried out in a multiethnic setting, namely Hawaii, and involved studying psychiatric in-patients from various ethnic groups (35-37). The behavior of these patients at two points in time was compared. In the hospital, psychiatric personnel applied Western clinical criteria dealing with the phenomenology of illness, whereas in the community lay persons (significant others) who had had contact with the patient prior to admission completed questionnaires about the patient's social behavior. These latter questionnaires inquired about a variety of clinically relevant social behaviors, and these behaviors were described in every-day language. The actual findings in these studies don't need to be mentioned. Significant is the fact that community norms and standards vis a vis deviant behaviors were used as a background against which the clinical behavior of hospitalized patients was evaluated, for it is these norms that "force" or prompt hospitalization. Let us elaborate upon this point. We will assume that members of ethnic group X (or for that matter culture X) judge a particular set of behaviors as normal, expected or appropriate and another set as deviant (DxvsD*l. A similar formulation
v

applied to another group Y would yield behaviors labeled Dya and DJJ, respectively. Now, it is behaviors D^ and Dyd that lead the patient or those responsible for him to seek medical care or hospitalization. Why this is the case requires explanation and involves probing the traditions, values and behavioral rules of the respective group. Explaining the presence of the behaviors in the first place involves sociocultural as well as genetic and other biological factors. The behaviors Dd and Bl may not, of course, be parallel and in fact may include segments that the contrasting group judges as "normal." Such socially defined "normal" behaviors can, if viewed biomedically, be judged as symptomatic or pathological. If this discrepancy is observed, then one is led to inquire into cultural factors for an explanation. To summarize, in any one social group, one is led to posit a series of classes or dimensions that may be used to classify social behaviors. These categories may be drawn by the observer from without, and they may or may not be consistent with categories that members of the group themselves use or follow. Moreover, the social behaviors, which are symbolically framed in a culturally distinctive manner, are empirically distributed in various ways. Members of the group segment, partition or grade such behaviors in terms of appropriateness, just as clinicians are wont to draw on the behaviors in evaluating psychiatric status. These two ways of looking at social behaviors are logically independent (7). Explaining the reasons why behavior is judged inappropriate in the group requires going into social culture considerations, although the bases for the behavior may rest heavily on noncultural factors. Distributions of behaviors (of a certain type) along the continuum of appropriateness need to be compared across

a'

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population groups. It is implicit in the researcher's formulation that the judgments and labels placed on such behaviors (eg, vis a vis deviance) and the actions implied by these labels will be substantially different across ethnic groups or cultures; such differences, moreover, will require a cultural explanation. Given these considerations, it should be clear why comparative studies based on hospitalized patients are of limited value in understanding generic questions about a disease such as depression: such'comparisons merely yield data on a certain subset of patients with a given disease, namely, those judged (for whatever reason) as problematic in their respective social groups. Problems Involving the Social Precipitants of Depression. The question of whether social factors play a role in precipitating depression raises several issues. One of these involves the definition of stress (38). We shall use the term situation, precipitants or even stressors to refer to environmental events or circumstances ' that are potentially problematic to the individual; the term "stress" will be used to signify the presumed internal organismic changes that may result from such situations and that can potentially interfere with the person's adjustment and adaptation. A reading of the social psychiatric literature will show that researchers do not ordinarily separate between these two categories conceptually, let alone empirically. Stressors, in short, are usually assumed a priori to produce stress and may, in fact, be used to signify stress. Conversely, the mere presence of depression is often taken to indicate that stress has in fact occurred. What is actually demonstrated, then, is simply an association between the clustering of stressors in persons who are also classified as showing depression. The inference is that the asso-

ciation is causal, though this cannot be proved except by psychological analyses or by using much more refined methods. It should be appreciated that the problem of evaluating empirically the influence of social stressors in depressive disease is confounded with the problem of what depression "is" and how it should be defined. For example, it has been shown that in so-called grief reactions one observes many of the phenomenologic features of the depressive state (39). Distinguishing between a grief reaction and a depression is clearly a difficult empirical problem and rests on criteria of definition. Any association between stressors and depression will differ depending on the extent to which purely descriptive factors (to the exclusion of situational ones) affect diagnostic criteria of depression. Along the same lines, a clinical truism is that strong affective reactions of a depressive sort occur as "stages" in pre-existing "psychiatric" disturbances such as alcoholism, anxiety neurosis and drug intoxication. Despite the fact that these "depressions" may include typical motoric and behavioral features viewed by many as diagnostic of depressive disease, arguments have been marshalled to the effect that such "secondary" depressions should be excluded from studies aimed at careful evaluation of social influences on the onset and course of a presumably separate entity, so-called primary depressions (6). It certainly is the case that the line between primary and secondary depressions can often not be precisely drawn empirically using phenomenologic criteria; furthermore, the causal linkages among the associated problems seen in secondary depressions can be interpreted differently, eg, drug abuse can often be seen as a way of coping with "primary" depressive feelings. These problems, of course, place an
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empirical burden on the researcher. One must grant that grief reactions and most so-called secondary depressions appeared tied logically to social circumstances; however, if they are both totally excluded from a category depression, then empirical inquiries into the influence of "social stressors" on depression are indeed somewhat suspect if one does not have definitional criteria that are independent of social circumstances and also do not include social behavior. It is difficult to support a strategy for evaluating social factors in a disease if potentially relevant ones are already being used indirectly to frame the definition of what is being evaluated, particularly so if remaining definitional criteria also bear on social matters. (See below and next section.) For this same reason, one cannot allow a concept "endogenous depression" to depend exclusively on the inability of a clinician to uncover a "clear" precipitating factor. In summary, one can note that how one defines depression will have an important influence on empirical attempts to measure the role of social stressors.

social psychiatric inquiries: the attempt to establish independence between, on the one hand, social events involving a person that both affect and reflect on psychological status, and, on the other, psychiatric disease that is defined on the basis of psychological status. A related problem is deciding on the length of the time interval preceeding the onset of disease that one will allow "stressors" to occupy. This interval will depend on the investigators model of how the disease develops. This question of etiology brings in once again the issue of the definition of depression. The role of hospitalization in complicating the evaluation of social stressors in the onset of depression cannot be overestimated. The complication produced by hospitalization in this evaluation is similar to the role hospitalization plays in the interpretation of social epidemiological findings. Since patients who are classified as depressive ordinarily are selected and interviewed in hospitals, so called stressors tend to be evaluated in relation to depression and often, inadvertently, in relation to the issue of hospitalization itself. Events and situations we may term Obviously, few psychiatric diseases begin stressors and that are related to the social with hospitalization, and furthermore, placement of the person may precede the those stressors that antedate hospitalizaonset of depression, in which case they tion may not necessarily be the same as could be given a causal role. However, de- those that antedate the onset of depressive ciding when a disease "begins" is a very disease. The question of the timing of the difficult matter. Since a person who is stress is obviously all important. However, developing a depression can be expected the issue of hospitalization is problematic to show changes in social behavior and in still another way. Even though investiperformance (see subsequent section), one gators may be careful to interview about must assume that interpersonal difficulties stressful situations using onset of depresof various sorts are more likely (eg, loss sion and not hospitalization as the point of job, marital discord) so that what in a of focus, the fact that the sample of destudy appears as a potential "cause" of de- pressives is usually formed in the hospital pression may in fact represent a conse- means that some bias was probably operatquence. Deciding between these alterna- ing nevertheless. Persons who seek (or are tives again involves matters of definition brought in for) formal care may be the and reflects directly a central problem of ones who are more pliable and who are 392
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characterized by greater responsiveness to and trust in the social system. These factors, in turn, may mean that they show a differential vulnerability to so-called social precipitants. The findings of Morrison and Hudgens who evaluated the influence of a number of life events in affective disorders using hospitalized medical and surgical patients as controls were notable precisely because they failed to turn up striking differences (40,41). Patients classified as having an affective disorder, when compared to the controls, only showed more frequent changes of residence and reported interpersonal discord during the year prior to admission, but this was usually after the disease had become manifest. It is possible that hospitalization, which all patients shared, was a factor that obscured the differential role of stressors in the onset of affective disorder. All patients, in other words, may have been selected in terms of their general responsivity to social influences symbolized in this instance by their readiness to turn to the hospital. In addition, of course, the fact that the control group was composed of persons showing disease of various types further complicates matters. A large body of research points to the importance of social stressors in the onset of a number of diseases not just the so-called psychiatric ones (42). In short, since persons who were placed in the categories depressive or "control" may both have been "affected" by the social stressors, any unique influences tied to the disease depression would have been obscured. It is, of course, desirable to compare how stressors affect various types of disease. However, an altogether different design is required if this problem, as well as the one involving social stressors and depression, are to be clarified. In summary, a clear and unambiguous

answer to the question of the influence of environmental factors on the onset of depression would seem to require first the availability of a definition that is anchored in unproblematic indicators of this disease. One must then uncover by means of field studies persons showing untreated as well as treated instanciations of "depression." These persons must then be systematically compared, in terms of frequency of "social stressors" that antedated the disease, with subjects who are nondepressives but ill and also with others who are not ill at all, all of whom are drawn from the roster of community residents. Ill persons, both depressives and nondepressives, should be classified as to whether they are or are not in treatment. In short, in order to determine whether social precipitants play a unique role in the onset of depression, one must establish that any association that exists between depression and the clustering of such precipitants does not result from (1) random factors that also affect normals, (2) selective factors associated with treatment and (3) effects attributable to the general category illness. Additional Problems Posed by Social Behaviors of Depressives. How depression influences social performance has been the focus of a great deal of research recently. Terms such as social performance and also social disability (43) are used to signify how persons function in the social system, ie, how well they meet role obligations. Since the very indicators of depression refer to (or are derived from inferences about) social behaviors, an evaluation of the social performance of depressives involves matters of definition raised earlier. We saw, for example, that the question of the comparative prevalence of depression involved the matter of how depression might be "expressed" in contrasting eth393

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nic and cultural communities; this obviously requires the appraisal of what passes as normal and abnormal social behavior. One may assume that an instance of depression is associated with specific neurochemical changes. It is still the case, however, that these changes, if not "caused" by conflicts in role obligations, are nevertheless likely to be observed in persons showing difficulties in the performance of social roles. Empirically, then, fundamental changes of depression (the significata mentioned earlier) are probably correlated with changes in social behavior. At the same time, one must recall that it is only by being directed to persons who may show role difficulties and then by being able to demonstrate these that the investigator or clinician is likely to diagnose depression. In short, built into the definition of what depression is and its identification onefindsa form of indeterminancy growing out of the direct linkage the disease has with social behavior. The excellent series of papers conducted by Paykel and his associates may be used as illustrations of how the social behaviors of depressives have been investigated (44,45). Drawing on items from earlier scales, these workers developed a Social Adjustment Scale (SAS). The items of this scale could be ordered into either of two sets or classes of social behaviors, termed by them role areas (eg, work, parental, etc) and qualitative (eg, behavior performance, feelings and satisfactions, etc). It is to be emphasized that these two classifications of social behavior were not independent, so that, for example, items reflecting leisure role behavior could also be distributed into the various qualitative groupings. Using the SAS, three patterns of social performance scores were obtained that included the two already described (role area and qualitative) and an
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empirical one derived from factor analysis. The SAS was administered to 40 females showing a primary depressive disorder; 40 female residents of the same area as the patients served as controls. Interesting differences were reported. As can be anticipated, depressed females generally tended to score lower in most role areas and in most aspects of role behaviors. Depressed housewives scored particularly lower in instrumental role behaviors. Depressed women who worked outside the home, on the other hand, were only slightly impaired in this domain, although they did report considerable distress, friction and disinterest associated with social demands. Interestingly, although depressed women reported less interest in six, frequency of sexual relations with spouse did not differ markedly. It should be emphasized that it was in the expressive intrahousehold role activities that depressed women showed greatest impairment. The design of this study, like those of related ones involving the social functioning of depressives, does not permit establishing causal priorities, so that one cannot establish whether depression led to role difficulties or vice versa. Such studies, furthermore, point to a related dilemma that confronts one evaluating social aspects of any psychiatric disease: the tendency of persons classified as depressed to more frequently offer discrediting reports about social performance. Persons that are hurting and experiencing distress and dissatisfaction can be expected to more frequently solicit care and be counted in such studies as patients; consequently, any appraisals and evaluations of their behavior that they themselves volunteer will naturally reflect such sociophenomenologic features. Their actual behavior (ie, "objective," if indeed this category has any meaning) may not

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necessarily indicate the presumed impairment that the subjective report suggests, although short of direct observation the clinician has no way of evaluating this. Evaluating the social behavior of a person as such behavior is perceived by significant others may avoid this self-reporting bias. However, this approach introduces an additional problem stemming from the observer's own view of and feeling toward the patient. Indeed, one may be led to question the meaning and usefulness of making diagnostic impressions and/or behavioral evaluations with regards to a particular person on the basis of reports that are proffered by others who are, so to speak, parties to any "disturbed behaviors" that may prevail. It should be clear that this dilemma, like the one raised earlier involving the indeterminancy of depression, is inevitable given the epistemelogical nature of psychiatric disease and human behavior. The "data" of psychiatry are embedded in social relations and partake of its logic and rationale, and the attempt to measure or evaluate such behavior on an independent basis raises epistemelogical questions. We have so far seen that the social behaviors of depressives affect evaluation of precipitants in this disease as well as the question of how depressives function. There is a related problem, namely, that of when, how and why an instance of depression terminates. Problems posed by the attempt to evaluate the duration of depression are thus involved. Clearly, considerations involving the beginnings of depression also apply logically to that of termination, but to avoid obvious redundancy these will not be discussed. Instead, we will deal with a similar but strictly speaking separate issue, and that involves the issue of how secondary social labeling may retard the resolution of de-

pressive disease and possibly even mask its "true" end point. Social scientists have graphically pointed out how deviations in the performance of basic social roles come to be viewed as abnormal and as possible indications that the individual is not well or "mentally ill." Such primary social labeling, which is very much associated with the internal organismic processes that lead to the development of disease, has been well discussed in the literature (46). Secondary social labeling, however, occurs after an individual already shows the characteristic evidence of disease, is diagnosed by relevant medical personnel and is exposed to psychiatric treatment. Our claim here is simply that by viewing an individual as still sick, by continuing to offer treatment and by recommending and expecting further psychiatric contacts mental health personnel may unwittingly be masking or concealing when an instance of depression ends. Natural end points of the depressive process may be missed, or remnants of the process nurtured and reinforced. The result is the same, the unnecessary prolongation of treatment and an implicit communication to the patient that he is still sick. Stated differently, either by aggressive, authoritarian or intensive involvements such personnel may frighten and literally coerce patients into continued treatment. Clearly, many depressive patients by definition demonstrate passivity, a sense of helplessness, a need for positive reinforcement, a lack of inner directedness, etc., and turn to psychiatric personnel in the hope of obtaining a "cure." Thus, what from one standpoint appear as typical indicators of depression, from another can be viewed as a set of compliant behaviors that characteristically form a part of the so-called sick role. What is part of a disease fits in
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logically with what is expected of a patient, and a continuation of such a patient status may pass as disease when in fact the underlying organismic changes that set the disease in motion are no longer in evidence. A consequence of the above, quite obviously, is that the duration of an occurrence of depression is not only a function of strictly medical issues but also to some extent partially created by psychiatric personnel and partially the outcome of socioprocessual and not disease matters. Thus, such issues as where or how far a patient resides from a treatment agency, his access to transportational means, his degree of distrust or need for self-definition and the extent to which treatment networks are proliferated and interconnected in an area will determine how long a patient stays in treatment, ie, the "duration" of his depression. Two conclusions can be entertained. First, one needs to adopt a critical posture when evaluating literature that centers on how long episodes of depression last. Secondly, in our own clinical work and in our researches we need to be candid and try hard to ascertain criteria that will separate disease manifestations from social behaviors that form a part of the patient's expected role; behaviors that we ourselves may have a hand in perpetuating and possibly to some extent also in generating. SUMMARY In this paper, some theoretical and methodological problems associated with the study of depression in relation to social systems were discussed. The first section initially concentrated on how the term "depression" might be handled as a purely abstract and logical entity in the con396

text of general medicine. Then, ordinary ways in which changes referred to by this term could be handled in relation to culture and society were described. In essence, this involved concentrating on the semantics of the term "depression." Some questions and emphases that are ordinarily overlooked in cross-cultural studies come to light when a linguistic analysis of this sort is undertaken. These issues were explored in the paper. In particular, two general themes were emphasized. On the one hand, the various kinds of changes that can be implicated and signified by "depression." These changes need to be seen as more or less independent on logical grounds if we are to achieve a clear biocultural understanding of what "depression" is. On the other hand, emphasis was given to how members of a particular culture can assign meaning and interpretation to the behavioral regularities that can be signified by "depression," as for example coming to view them as representing a disease that by definition is problematic, undesirable and in need of understanding, control and elimination. The second section of the paper dealt with problems devolving from the study of "depression" in Western nations where the changes signified by the term are in fact seen as constituting a disease, and where, presumably, definitional and logical issues are less problematic. Nevertheless, in such socio-epidemiologic analyses of a psychiatric disease such as depression one still encounters certain theoretical problems that need to be made explicit. We believe that some of these problems are peculiar to psychiatry, a discipline whose disease indicators have heretofore partaken of and been rooted in social behaviors. The logical relation that exists between the disease depression and social behaviors makes it difficult to de-

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velop suitable criteria of when the disease begins and ends. Other problems such as those involved in evaluating hospital rates or establishing community morbidity measures are generic to the field of epidemiology. Even in these cases, however,

the fluid nature of depression, in particular, the fact that the components of the disease mean different things to members of various social groups, create special analytical difficulties that must be taken into account in evaluating empirical results.

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