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225 pp Price £19.95 ISBN 0-19-852632-6 (p/b)
Oxford: Oxford University Press.
In our darwinian societies, professions can behave much like species in the natural world. The activities of successful ones tend continually to enlarge their niche space, often at the expense of competitors. One has only to look at the proliferation of lawyers or accountants to see that this is true. Medicine too has achieved 'success' of this sort. The dynamic behind it, though, can sometimes produce results at odds with both explicit professional goals and the intentions of individual practitioners. The sad histories of lying-in hospitals in the 18th century, or neurasthenia in the 19th, provide good examples of how expansion of medicine into neighbouring territories helped to create, rather than relieve, illness and disability.
Christopher Dowrick's thoughtful, sensitive and sometimes poetic book makes a good case for supposing that the present, perceived, epidemic of depression derives from causes more closely related to the 'ecology' of our profession than the condition of our patients. Dowrick, a general practitioner and academic in Liverpool's primary care department, pinpoints four principal factors, namely:
There is, in chapter 2, an excellent and quite erudite summary of the reasons for supposing that depression should be regarded as a medical condition much like any other. Later on, however, Dowrick cogently argues that this is something of an illusion. At times he verges on falling into the opposite error, by seeming to imply that it may never be illness-like. Despite this, his argument is convincing overall. Depression is a term like 'bellyache', not like 'appendicitis'. Most bellyaches may be non-pathological and some even benign, but appendicitis does occasionally occur. It may be significant that Dowrick mentions melancholy, grief, angst, accidia, anomie, ennui, even the Buddhist concept of dukkha (suffering), but melancholia does not appear—and this was the concept most closely related to the 'illness' aspect of depression. Though he may have a bit of a blind spot for actual depressive illness, probably deriving from his perspective in general practice, there seems little doubt that his general scepticism about the worth of ever-proliferating diagnoses of depression is correct. One particularly neat piece of evidence derives from a survey of general practice patients which identified those with 'depression'. It showed that patients whose depression remained undetected by their GPs were better on average at follow-up than those whose condition was recognized, though there had been little difference between the two groups initially.
Believing as he does (rightly so in my opinion) that doctors are at least as much part of the problem as part of the solution when it comes to the spread of depression, Dowrick faces a 'Catch-22' dilemma when recommending how individual cases of 'depression' should be treated. In the course of a nice cross-cultural account of negative emotions, he comes perilously close to suggesting that cases should be told to put up with their feelings and make the best of their situations—perhaps with the aid of advice and emotional support from a family practitioner. This may work for some but, applied generally, sounds far from a good idea! Surely further research is needed in order to allow us to distinguish the 'appendicitises' from the 'benign bellyaches' and, in the interim, each case must be dealt with individually and pragmatically. The trouble with further research is that much of it will be funded by drug companies who in their dreams would like us all to be suffering from generic 'depression' and swallowing their product. All the same, truth will eventually out.
Anyone may appreciate this book for its nice case histories, poetry and snippets of cultural information. I recommend it particularly, however, to those on the receiving end of antidepressant drug advertising and especially for psychiatrists who go along with their College in thinking that raising public awareness of 'depression' is an unmitigatedly good idea. Of course, our darwinian professional dynamic will almost certainly result in attempts to sweep Dowrick's message under the carpet, or even in efforts to shoot the messenger. Let's hope they don't succeed.