The Age of Melancholy: "Major Depression" and Its Social Origins
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《新英格兰医药杂志》
In the latter half of the 20th century, there was a steep increase in the prevalence of diagnosed major depressive disorder; soon, this disorder is expected to become the second-largest contributor to the global burden of disease. What accounts for this remarkable increase? Do the prevailing explanations of the disorder have implications for the care of, and perhaps the cure for, people struggling with mental illness?
In The Age of Melancholy, Dan Blazer explores the social origins of major depression, from melancholia in the Hippocratic era to the bifurcation of depression into the endogenous and reactive forms proposed in the late 19th century. In this book, unlike other histories of depression, Blazer focuses little attention on the pharmaceutical industry, and the overmedication of depressed mood is not at the center of his lament. He notes, however, that the focus on medications has resulted in an impoverishment of our thinking about the social and cultural forces that affect mental health. In one chapter, Blazer draws on the lessons from our changing concepts of "war syndromes" to underscore his argument that the profession is moving away from the concept of major depression as having indistinct etiologic, diagnostic, and prognostic boundaries and toward the reification of depression as a specific diagnosis with specific pathologic origins and requiring specific treatments. The end result, claims Blazer, is "an unfortunate constriction of psychiatric thought."
The "swelling prevalence" of major depression, in Blazer's view, is related to the decline of modernity and the "increasingly dominant hopelessness" in the wake of the postmodern critique. This hopelessness, according to Blazer, has undermined people's individual narratives and the meta-narratives that are the bases of their worldviews — resulting in a thoroughly "depressogenic" environment. Modern psychiatry is poorly equipped to deal with the postmodern challenge: "If psychiatry is the product of a culture preoccupied with rationality and the individual self, what sort of mental health care is appropriate in a world in which such preoccupations are waning?" In modern psychiatry, meta-narratives are disregarded, and the search for meaning is marginalized, as efforts to identify neurochemical imbalances increasingly treat the depression rather than the patient who has the depression. Unfortunately, the ways in which modern psychiatry has responded to the suffering of its patients led Blazer to ask whether "thoroughly modern utilitarian psychiatry missing something."
Recovering an orientation toward social psychiatry may help modern psychiatry find its soul, according to Blazer. As he notes, social psychiatry flourished in the 1950s and 1960s, but its "excesses" resulted in its decline and the subsequent crowning of researchers and practitioners oriented toward psychobiology. Although Blazer clearly regards the decline of social psychiatry as an ill-fated turn of events, The Age of Melancholy is not written as a polemic. Refreshingly, he enters this conversation not by arguing that psychobiologic investigation ought to be curtailed or by making common cause with social constructionists and antipsychiatrists but, rather, by highlighting two models that link biologic diatheses to social environments. He exhorts his colleagues to recover the social roots of psychiatry and calls for a "new wave of basic social science research in the service of the mentally ill" that should be regarded, in his view, as intrinsic ("complement is too weak a term") to current psychobiologic and clinical research.
The Age of Melancholy is well organized and user-friendly enough for specialists and nonspecialists alike. Its readability is enhanced by the vignettes interspersed throughout the text, which connect Blazer's scholarly observations to actual patients, research projects, and personal experiences.
Blazer has written a book with immediate relevance to the field of psychiatry. His analysis sharpens our understanding of the ways in which scholarship in psychiatry can and must improve for the sake of patients. He should be thanked for writing this book.
Alexander C. Tsai, Ph.D.
Case Western Reserve University School of Medicine
Cleveland, OH 44106(By Dan G. Blazer. 251 pp.)
In The Age of Melancholy, Dan Blazer explores the social origins of major depression, from melancholia in the Hippocratic era to the bifurcation of depression into the endogenous and reactive forms proposed in the late 19th century. In this book, unlike other histories of depression, Blazer focuses little attention on the pharmaceutical industry, and the overmedication of depressed mood is not at the center of his lament. He notes, however, that the focus on medications has resulted in an impoverishment of our thinking about the social and cultural forces that affect mental health. In one chapter, Blazer draws on the lessons from our changing concepts of "war syndromes" to underscore his argument that the profession is moving away from the concept of major depression as having indistinct etiologic, diagnostic, and prognostic boundaries and toward the reification of depression as a specific diagnosis with specific pathologic origins and requiring specific treatments. The end result, claims Blazer, is "an unfortunate constriction of psychiatric thought."
The "swelling prevalence" of major depression, in Blazer's view, is related to the decline of modernity and the "increasingly dominant hopelessness" in the wake of the postmodern critique. This hopelessness, according to Blazer, has undermined people's individual narratives and the meta-narratives that are the bases of their worldviews — resulting in a thoroughly "depressogenic" environment. Modern psychiatry is poorly equipped to deal with the postmodern challenge: "If psychiatry is the product of a culture preoccupied with rationality and the individual self, what sort of mental health care is appropriate in a world in which such preoccupations are waning?" In modern psychiatry, meta-narratives are disregarded, and the search for meaning is marginalized, as efforts to identify neurochemical imbalances increasingly treat the depression rather than the patient who has the depression. Unfortunately, the ways in which modern psychiatry has responded to the suffering of its patients led Blazer to ask whether "thoroughly modern utilitarian psychiatry missing something."
Recovering an orientation toward social psychiatry may help modern psychiatry find its soul, according to Blazer. As he notes, social psychiatry flourished in the 1950s and 1960s, but its "excesses" resulted in its decline and the subsequent crowning of researchers and practitioners oriented toward psychobiology. Although Blazer clearly regards the decline of social psychiatry as an ill-fated turn of events, The Age of Melancholy is not written as a polemic. Refreshingly, he enters this conversation not by arguing that psychobiologic investigation ought to be curtailed or by making common cause with social constructionists and antipsychiatrists but, rather, by highlighting two models that link biologic diatheses to social environments. He exhorts his colleagues to recover the social roots of psychiatry and calls for a "new wave of basic social science research in the service of the mentally ill" that should be regarded, in his view, as intrinsic ("complement is too weak a term") to current psychobiologic and clinical research.
The Age of Melancholy is well organized and user-friendly enough for specialists and nonspecialists alike. Its readability is enhanced by the vignettes interspersed throughout the text, which connect Blazer's scholarly observations to actual patients, research projects, and personal experiences.
Blazer has written a book with immediate relevance to the field of psychiatry. His analysis sharpens our understanding of the ways in which scholarship in psychiatry can and must improve for the sake of patients. He should be thanked for writing this book.
Alexander C. Tsai, Ph.D.
Case Western Reserve University School of Medicine
Cleveland, OH 44106(By Dan G. Blazer. 251 pp.)