Derek Summerfield, consultant psychiatrist at South London and Maudsley National Health Service Foundation Trust, challenges the assumption that Western depression is a universal condition. In a recent commentary, published in The British Journal of Psychiatry, Summerfield responds to a study led by Graham Thornicroft on the undertreatment of Major Depressive Disorder globally. Summerfield argues that the Western construct of depression is not valid in many countries.
“Biologically triumphalist studies like this simply have to be challenged, because once something—in this case, depression as a unitary pathological entity arising naturalistically anywhere in the world—is declared real, it becomes real in its consequences,” writes Summerfield.
Thornicroft and colleagues investigated the prevalence of Major Depressive Disorder, as defined by the DSM-IV, in 21 countries of varying income-level. The researchers found an average of 4.6% of study respondents met criteria for Major Depressive Disorder within the past year. They also argued that only a minority of people are receiving “minimally adequate treatment” for depression, which they identified as (a) at least one month of pharmacotherapy with at least four visits to a medical doctor, or (b) at least eight psychotherapy sessions.
“Thornicroft et al assume that ‘mental disorder’ is an entity essentially lying outside situation, society, and culture, which is identifiable anywhere using a common (Western) methodology.”
He challenges the World Health Organization’s claim, cited by Thornicroft and colleagues, that Major Depressive Disorder is the second leading cause of years lived with disability (DALY) worldwide, describing the DALY measurement as “epistemologically lamentable.”
Summerfield states, “diagnoses are merely descriptive constructions, conceptual devices, and are drawn up by us, not by nature.”
He argues that ‘depression’ often does not have an equivalent in non-Western cultures because the notion of emotions—experiences that are internal, biologically-driven, and separate from thoughts—is not a universal concept.
Thornicroft and colleagues acknowledged the limitations of their survey instruments’ validity across cultures. However, Summerfield argues that the researchers’ conclusions did not take these limitations into account.
He writes, “Invalid approaches cannot be redeemed by ‘reliability’—using a standard, reproducible method—since the very ground they stand on is unsound.”
In light of the recent call to implement routine screening for depression internationally, Summerfield’s reminder that the Western understanding of depression is not universal is critical. Summerfield concludes by reflecting on his own home country, Zimbabwe. He writes:
“Does Africa need the category of Western depression at all, and does it need the marketing of antidepressants which will ride on the back of papers like this in international psychiatric journals? I think not.”
Summerfield, D. A. (2017). Western depression is not a universal condition. The British Journal of Psychiatry, 211(1), 52. doi: 10.1192/bjp.211.1.52 (Link)