There are important geographical variations in the prevalence of depression, and these can in large part be accounted for by socio-cultural factors. In traditional societies, human distress is more likely to be seen as an indicator of the need to address important life problems, rather than as a mental disorder requiring professional treatment. For this reason, the diagnosis of depression is correspondingly less common. Some linguistic communities do not have a word or even a concept for ‘depression’, and many people from traditional societies with what may be construed as depression present with physical complaints such as headache or chest pain rather than with psychological complaints. Punjabi women who have recently immigrated to the UK and given birth find it baffling that a health visitor should pop round to ask them if they are depressed. Not only had they never considered the possibility that giving birth could be anything other than a joyous event, but they do not even have a word with which to translate the concept of ‘depression’ into Punjabi!
In modern societies such as the UK and the USA, people talk about depression more readily and more openly. As a result, they are more likely to interpret their distress in terms of depression, and less likely to fear being stigmatised if they seek out a diagnosis of the illness. At the same time, groups with vested interests such as pharmaceutical companies and mental health experts promote the notion of saccharine happiness as a natural, default state, and of human distress as a mental disorder. The concept of depression as a mental disorder may be useful for the more severe and intractable cases treated by hospital psychiatrists, but probably not for the majority of cases, which, for the most part, are mild and short-lived, and easily interpreted in terms of life circumstances, human nature, or the human condition.
Another (non-mutually exclusive) explanation for the important geographical variations in the prevalence of depression may lie in the nature of modern societies, which have become increasingly individualistic and divorced from traditional values. For many people living in our society, life can seem both suffocating and far removed, lonely even and especially amongst the multitudes, and not only meaningless but absurd. By encoding their distress in terms of mental disorder, our society may be subtly implying that the problem lies not with itself, but with them. However, thinking of the milder forms of depression in terms of an illness can be counterproductive, as it can prevent people from identifying and addressing the important life problems that are at the root of their distress.
Adapted from The Meaning of Madness.
In 2008, just 6% of candidates sitting Paper 1 of the MRCPsych exam were UK graduates, evidence if any were needed that recruitment into psychiatry is facing an unprecedented crisis.
In my experience, most medical students enjoy learning about mental illness and talking to mentally ill people, who often have a refreshing knack for saying things exactly how they are. In a fit of inspiration, some medical students tell me that psychiatry is the only specialty that enables them to think about themselves, about other people, and about life in general. They also like the lifestyle: an hour for each patient, ‘special interest’ days, protected time for teaching, light on calls from home, and guaranteed career progression. In medicine they might treat yet another anonymous case of asthma, chest pain, or pulmonary oedema. In surgery they might do one knee replacement after another, up until the day they retire or collapse. But in psychiatry there can be no factory line, no standard procedure, and no mindless protocol: each patient is unique, and each patient has something unique to return to the psychiatrist. I often come across those same students again, months or sometimes years later. After the smiles and the niceties, it transpires that they are no longer so interested in psychiatry. So what happened?
The students are never too sure, but I think I have an idea. Whilst I was a medical student in London, an American firm offered me a highly paid job as a strategy consultant in their Paris office. So I gladly left medicine, and the many inconveniences of working in (and increasingly ‘for’) the NHS. I had a great time in Paris, but the job itself turned out to be more about dealing with personality disorders than about having good ideas. I quit after six months and freelanced as an English tutor to high-flying executives, bankers, venture capitalists, and such like. As my clients already spoke good English and merely wanted to improve their fluency, all I had to do was to make conversation with them. My lessons often turned into something akin to psychotherapy, as I realised that I could make my clients open their hearts and minds simply by listening to them speak. Although they seemed to have everything in life, they were actually deeply unhappy, and had rarely stopped to ask themselves why. I wanted to find out why, so I decided to go back to the UK, do my house jobs, and specialise in psychiatry. I had always been far too ‘ambitious’ to consider psychiatry, but by then it had become clear that I didn’t want to pursue a career that didn’t allow me to think and feel, and to relate to others and to the world in a genuine and meaningful way. There are not many such jobs, but psychiatry – along with general practice, teaching, academia, and the clergy – is certainly one of them, and is even, arguably, their archetypal form.
The following year whilst going about my house jobs I put up with all sorts of abuse from my colleagues in medicine and surgery. One of the other house officers, by then a good buddy, took me aside one day and said with an alcoholic mixture of concern and disdain: ‘Why do you want to go into psychiatry? You’re a good doctor. Can’t you see you’re wasting your talents?’ It became very clear, first, that the stigma that people with a mental disorder are made to feel also extends to the doctors who look after them; and, second, that this stigma emanates most strongly from the medical profession itself, mired as it is in middle class preoccupations and prejudices and, as a whole, far too grounded in neurosis not to be terrified of psychosis.
Of course, it is simply not true that psychiatry is ‘a waste of talent’. The term ‘psychiatry’ was first used 200 years ago in 1808, in a 188-page paper by Johann Christian Reil. He argued for the urgent creation of a medical specialty to be called ‘psychiatry’, and contended that only the very best physicians had the skills to join it. These physicians needed not only to have an understanding of the body, but also a much broader range of skills than standard physicians. Indeed, a psychiatrist can change a person’s entire outlook with a single sentence, so long as he can find the right words and the right time. No protocols, no high-tech equipment or expensive drugs, no pain or side-effects, and no complications or follow-up. Now that is talent, and one so great that I can only ever aim at it. And each time I fail, I always have medicine to fall back on.
Posted on 26/07/2010: A recent update on the recruitment crisis facing psychiatry can be found here.