Exporting Depression

Ethan Watters

January 12, 2013

When people ask me how I began working on my last book, Crazy Like Us, I tell them about meeting Dr. Laurence Kirmayer at McGill University back in 2005. He took time one afternoon to tell me a remarkable story about a personal encounter he had with the pharmaceutical giant GlaxoSmithKline and the remarkable resources that the company employed over the last decade to make their antidepressant pill Paxil a best seller in Japan.

The story he told began in the fall of 2000, when he received an invitation from something called the International Consensus Group on Depression and Anxiety to an all-expenses-paid conference in Kyoto. Accepting the invitation didn’t at first seem like a difficult decision, he said. Although he knew that the conference was sponsored by an educational grant from the drug maker GlaxoSmithKline, such industry funding wasn’t unusual for academic conferences in the field of psychiatry.

When he checked out the list of other invitees, he recognized most of the names. Like himself, other attendees were experts in the question of how culture informs and shapes the experience of the mentally ill. “I wouldn’t say it was a no-brainer, but it wasn’t very hard for me to say yes,” Kirmayer remembers. “How much trouble could I get in?”

His first inkling that this wasn’t a run-of-the-mill academic conference came when the airline ticket arrived in the mail. This ticket was for a seat in the front of the plane and cost nearly $10,000. On arrival in Kyoto in early October 2000, he found the luxury of the accommodations to be beyond anything he had personally experienced. He was ushered into an exclusive part of the hotel, where he was given a drink while an attractive woman filled out the hotel forms. His room was a palatial suite. The bath was drawn and strewn with rose petals and dosed with frangipani oil.

“This was Gordon Gekko treatment—the most deluxe circumstances I have ever experienced in my life,” Kirmayer told me, smiling at the memory. “The luxury was so far beyond anything that I could personally afford, it was a little scary. It didn’t take me long to think that something strange was going on here. I wondered: What did I do to deserve this?”

It was clear from the start that the gatherings of the International Consensus Group on Depression and Anxiety were different from the normal drug company dog and pony show, and not simply because the enticements being offered were so dear. Once the group of academics actually gathered in a plush conference room and began their discussions, Kirmayer realized that the GlaxoSmithKline representatives in attendance had no interest in touting their products to the group. Indeed there was little mention of the company’s antidepressant drug Paxil, which was just a few months away from hitting the market in Japan. Instead they seemed much more interested in hearing from the assembled group. “They were not trying to sell their drugs to us,” Kirmayer remembers. “They were interested in what we knew about how cultures shape the illness experience.”

The drug company representatives weren’t from the ranks of the advertising or marketing departments or the peppy salespeople. As best Kirmayer could tell, these were highly paid private scholars who could hold their own in the most sophisticated discussion of postcolonial theory or the impact of globalization on the human mind. “These guys all had PhDs and were versed in the literature,” Kirmayer said. “They were clearly soaking up what we had to say to each other on these topics.”

The intense interest the GlaxoSmithKline brain trust showed in the topic of how culture shapes the illness experience made sense given the timing of the meeting. The class of selective serotonin reuptake inhibitors (SSRIs) had become the wonder drug of the 1990s, at least in terms of the profits they’d garnered for the drug companies. That year alone, in the leading regions for SSRIs, sales grew by 18 percent and totaled over thirteen billion dollars. Most of those sales were still in the United States, but there was wide agreement that lucrative international markets had yet to be tapped. Indeed it was somewhat remarkable that none of the best-selling SSRIs had been launched in Japan.

What caused this uncharacteristic timidity on the part of these pharmaceutical giants? Eli Lilly, then the out-front world leader in the SSRI horserace with Prozac, had decided in the early 1990s not to pursue the Japanese market because executives in the company believed that the Japanese people wouldn’t be interested in taking the drug. More precisely, they wouldn’t want to accept the disease. Although there was a psychiatric term for depression in Japan, utsubyô, what it was considered a chronic and devastating disorder – the sort that would land you in a psychiatric ward for weeks or months. Utsubyô was seen as an illness that would make it impossible to hold down a job or have a semblance of a normal life. Worse yet, at least for the sales prospects of SSRI sales in Japan, utsubyô was considered a rare disorder.

“The people’s attitude toward depression was very negative,” explained a spokeswoman for Eli Lilly to the Wall Street Journal. She was referring to the fact that the Japanese had a fundamentally different conception of depression than in the West, one that made it unlikely that a significant number of people in Japan would want to take a drug associated connected to the disease.

At the Kyoto meeting Kirmayer began to understand GlaxoSmithKline’s intense interest in the question of how cultures shape the illness experience. To make Paxil a hit in Japan, it would not be enough to corner the small market of those diagnosed with utsubyô. The objective was to influence, at the most fundamental level, the Japanese understanding of sadness and depression. In short, they were learning how to market a disease.

To have the best chance of shifting the Japanese public’s perception about the meaning of depression, GlaxoSmithKline needed a deep and sophisticated understanding of how those beliefs had taken shape. This was why, Kirmayer came to realize, the company had invited him and his colleagues and treated them like royalty. GlaxoSmithKline needed help solving a cultural puzzle that might be worth billions of dollars.

After lunch on the second day of the conference, it was Kirmayer’s turn to speak. He had written many papers in his career documenting the differing expressions of depression around the world and the meaning hidden in those differences. He had found that every culture has a type of experience that is in some ways parallel to the Western conception of depression: A mental state and set of behaviors that relate to a loss of connectedness to others or a decline in social status or personal motivation. But he had also found that cultures have unique expressions, descriptions, and understandings for these states of being.

He told the assembled scholars and drug company representatives of how a Nigerian man might experience a culturally distinct form of depression by describing a peppery feeling in his head. A rural Chinese farmer might speak only of shoulder or stomach aches. A man in India might talk of semen loss or a sinking heart or feeling hot. A Korean might tell you of “fire illness,” which is experienced as a burning in the gut. someone from Iran might talk of tightness in the chest, and an American Indian might describe the experience of depression as something akin to loneliness.

Kirmayer had observed that cultures often differ in what he called “explanatory models” for depression-like states. These cultural beliefs and stories have the effect of directing the attention of individuals to certain feelings and symptoms and away from others. In one culture someone feeling an inchoate distress might be prompted to search for feelings of unease in his gut or in muscle pain; in another place or time, a different type of symptom would be accepted as legitimate. This interplay between the expectations of the culture and the experience of the individual leads to a cycle of symptom amplification. In short, beliefs about the cause, symptomatology, and course of an illness such as depression tended to be self-fulfilling. Explanatory models created the culturally expected experience of the disease in the mind of the sufferer.

Understanding these cultural differences is critical, however, because culturally distinct symptoms often hold precious clues about the causes of the distress. The American Indian symptom of feeling lonely, for instance, likely reflects a sense of social marginalization. A Korean who feels the epigastric pain of fire illness is expressing distress over an interpersonal conflict or a collective experience of injustice. The wide variety of symptoms wasn’t the only difference.

Critically, not everyone in the world agreed that thinking of such experiences as an illness made sense. Kirmayer documented how feelings and symptoms that an American doctor might categorize as depression are often viewed in other cultures as something of a “moral compass,” prompting both the individual and the group to search for the source of the social, spiritual, or moral discord. By applying a one-size-fits-all notion of depression around the world, Kirmayer argued, we run the risk of obscuring the social meaning – the communication the symptoms are meant to impart.

The drug company representatives listened closely to Kirmayer’s presentation and thanked him heartily afterward. To this day, he’s not entirely sure what they took away from his presentation. In the end Kirmayer’s comments could have been taken in two ways. On the one hand, they could be seen as a warning to respect and protect the cultural diversity of human suffering. In this way, he was like a botanist presenting a lecture to a lumber company on the complex ecology of the forest. On the other hand, he might have told the Glaxosmithkline representatives exactly what they wanted to hear: that cultural conceptions surrounding illnesses such as depression could be influenced and shifted over time. He made that point clearly in the conclusion of the paper he wrote based on his presentation:

The clinical presentation of depression and anxiety is a function not only of patients’ ethnocultural backgrounds, but of the structure of the health care system they find themselves in and the diagnostic categories and concepts they encounter in mass media and in dialogue with family, friends and clinicians. In the globalizing world, he reported, these conceptions are in constant transaction and transformation across boundaries of race, culture, class, and nation. In this context, it is important to recognize that psychiatry itself is part of an international subculture that imposes certain categories on the world that may not fit equally well everywhere and that never completely captures the illness experience and concerns of patients.

In other words, cultural beliefs about depression and the self are malleable and responsive to messages that can be exported from one culture to another. One culture can reshape how a population in another culture categorizes a given set of symptoms, replace their explanatory model, and redraw the line demarcating normal behaviors and internal states from those considered pathological. Kirmayer’s appreciation of the irony of his brief encounter with GlaxoSmithKline has only grown over the years since he gave that presentation. “People like me got into cultural psychiatry because we were interested in differences between cultures—even treasured those differences in the same way a biologist treasures ecological diversity,” Kirmayer says. “So it’s certainly ironic that cultural psychiatrists sometimes end up being handmaidens to these global marketing machines that are intent on manipulating cultural differences . . . in order to capitalize on those changes.”

When asked how clear it was that GlaxoSmithKlinewas interested in changing notions of depression in Japan, Kirmayer is unequivical. “It was very explicit. What I was witnessing was a multinational pharmaceutical corporation working hard to redefine narratives about mental health,” he said. “These changes have far-reaching effects, informing the cultural conceptions of personhood and how people conduct their everyday lives. And this is happening on a global scale. These companies are upending long-held cultural beliefs about the meaning of illness and healing.”

Ethan Watters

Crazy Like Us: The cultural shaping of mental health symptoms is often ignored by psychiatry. Watters reveals a remarkable diversity in the expression and outcome of major mental illnesses. Clients and practitioners can learned a great deal by viewing mental health across history and across cultures.

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8 thoughts on “Exporting Depression

  1. Thanks for your post-
    In the psychopathology class I teach, I talk about the differing ways in which age groups can label the same experience. With regard to depression, older individuals tend to complain about physical symptoms prior to a suicide, whereas younger people reference feeling sad. My own view of depression is that depressed mood is attributable to systemic inflammation. (I articulated the case for this in a recent article published on line in Frontiers of Psychology.) Systemic inflammation manifests in both mood and bodily symptoms. Either description of one’s state is accurate. My question is whether people are better off labeling themselves as “coming down with the flu” or “being depressed”. The late psychotherapist Jay Haley advised the therapist he trained to “define the problem in such a way that it has a solution”. My guess is that deciding one is coming down with a cold is far better than deciding one has a major mental illness. The former is temporary, the latter is forever.

    • Interestingly GSK marketed depression in Japan as a “cold of the soul.” It was a great slogan in that it suggested that sort term unhappiness (like short term illness) could be seen as something you might take a pill for. The outcomes of these sorts of cultural incursions are not necessarily all good or all bad. My point more is that we rarely even consider the consequences of exporting our beliefs about mental illness and healing. GSK has had enormous success selling paxil in Japan and convincing a large chunk of the population that their sadness is depression. I worry about the consequences and believe the results are largely on the negative side of the ledger. The science behind the efficacy of SSRIs is problematic at best and a scandal at worst.

      But I’m not willing to go so far as to say their might not be some people who were helped — either by the marginal efficacy of the drug or by the lessening of the stigma attached to the idea of depression. Suicide rates have recently leveled off in Japan although it is far from clear whether this has had anything to do with the acceptance of SSRIs. It’s a very complicated question and the jury is still out.

      Of course the consequences of the long term usage of such drugs by significant portions of a population (hat tip to Whitaker) remains to be tallied.

    • littrell, perhaps you can explain this to me. I’ve been looking for clarification everywhere.

      Can you tell me how grieving, for example, becomes depression after a couple of weeks? What is the model based on the inflammation theory you espouse?

  2. Cigarettes cause cancer and lung disease, Alcohol kills many in car crashes and other diseases. These are legal drugs.
    The problem with big Pharma “upending long-held cultural beliefs about the meaning of illness and healing.” is that they sell “medicines” instead of “drugs”.
    “Diseases are malfunctions of the human body, of the heart, the liver , the kidney, the brain.”said Thomas Szasz.
    These drugs are not medicines, yet they are allowed to be called medicines. I don’t blame big Pharma for trying to make money, that is what drug dealers do.

      • Disease today, it was a “sin” in the past.
        Sins come from choices.
        “In our fervor to medicalize morals, we have transformed every sin but one into sickness. Anger, gluttony, lust, pride, sloth are all the symptoms
        of mental diseases. Only lacking compassion is still a sin.” wrote Thomas Szasz in his book titled “Cruel Compassion”.

  3. I thought a key sentence in the article was this: “Kirmayer documented how feelings and symptoms that an American doctor might categorize as depression are often viewed in other cultures as something of a “moral compass,” prompting both the individual and the group to search for the source of the social, spiritual, or moral discord.”

    I think in general our medical approach tends to deny the possibility that our emotional states might have meaning, and that this is making our whole culture increasingly socially, spiritually, and morally ignorant. I think this would be a problem with any culture that tried to deny the possibility that emotional states might be an indication of important issues that need to be resolved.

    I say “might” because sometimes our emotional states do have more to do with physical problems, maybe our sleep was off or we are withdrawing from some substance or something else, but often they point to bigger issues outside of ourselves, and when we are trained to not notice that, social problems just fester while those who sell us drugs or whatever prosper.

  4. Pharma engineered a cultural shift about “depression” in the US and Europe as well.

    Comparing models of “depression” across cultures highlights the destructiveness of the Euro-American one, which undermines individual autonomy and resiliency, replacing them with helpless dependence on drugs and “experts” and the expectation of endless treatment.

    I’m not an expert in cultural psychiatry, but it seems to me this model is quite malign. It does continue to generate profits for pharma, though, as people on chronic psychiatric medication, suffering side effects and thinking of themselves as forever ill, seek additional medical treatment for iatrogenic and other ailments.

    For example, psychiatric medications are a bonanza for diabetes treatments; metformin is being repurposed as an add-on for antipsychotics. Psychiatric medications often necessitate the use of sleep drugs. Iatrogenic stomach issues are treated with PPI drugs. And so forth.

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