problems implicit in the cultural and social study of depression

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Problems Implicit in the Culturaland Social Study of DepressionHORACIO FABREGA, JR., MD

This paper reviews issues and questions that are tied to the study of psychiatric disease inrelation to social systems. The specific focus is on the Western disease depression. The firstpart deals with problems arising when depression is examined in relation to culture. Thispart, which is largely analytical, points to problems inherent in the field of cultural psychiatry.The second part addresses problems involved in the study of depression in Western nations.Epidemiological questions as well as factors involving the influence of social factors in theonset, duration and manifestations of depression are given attention in the attempt to bringout fundamental dilemmas tied to the social study of psychiatric disease.

INTRODUCTIONSocial psychiatry represents an area ofinquiry in which one finds diverse typesof emphases. These can be divided, on theone hand, into pragmatic emphases, (asseen, for example, in community psychia-try) and on the other, into theoretical and

empirical ones that touch on how the var-ious psychiatric diseases are related to thesocial environment. In this paper wewould like to address some facets of thelatter tradition in social psychiatry. Brief-ly, we propose to examine the way inwhich psychiatric diseases have ordinarilybeen studied in relation to social systemsand to give principal attention to the logicof such inquiries. The aim is to bring tolight some problems tied to the culturaland social study of psychiatric disease. In-sofar as attention will be given to tradi-tional paradigms in social psychiatry, thepaper may be described as analytic. Itshould be understood, however, that aconsequence of such a form of analysis isFrom the Departments of Psychiatry and Anthro-pology, Michigan State University, East Lansing,Mich. 48824.Received for publication October 18, 1973; revis-ion received February 25, 1974.

often the achievement of a clearer perspec-tive towards empirical investigations,which in turn may feed back on policyand programmatic questions.The above described logical analysis ofpsychiatric disease is by nature generaland abstract. In order to make this endeav-or more specific and tangible it will dowell to focus on social factors of only onedisease entity. In this regard, we have cho-sen to concentrate on depression. This dis-order has played an important role inWestern medical history since ancienttimes and, furthermore, is currently theobject of much empirical research and dis-cussion (1-6). Consequently, clarifyingtheoretical aspects of depression high-lights controversies and ambiguities thathave played an important role in the evo-lution of psychiatry and which in fact arestill problematic even today. In addition,the changes associated with depressionare such that they highlight important andalso generic problems that are germane tofields of both medicine and social science.In short, examining theoretical aspects ofthe relation between depression and socio-cultural systems not only involves dealingwith long standing and essentially un-solved theoretical problems within psy-chiatry proper, but also addresses ratherPsychosomatic Med icine V ol . 36, No . 5 (September-October 1974) 377C opy r i gh te 1974 by the American Psychosomatic Society, Inc.Published by American Elsevier Publishing Company, Inc.


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HORACIO FABREGA, JR.fundamental questions about the relationsbetween disease, medicine and societygenerally (7).

THE IDEA OF DISEA SEA N D T H E I D E AOF PSYCHIATRIC D ISEASE

From a logical standpoint, we can saythat disease constitutes a person-centeredundesirable deviation in the value or val-ues of a cluster of related biological indi-cators. Disease indicators are deviations inspecial biologically relevant variables (eg,blood pressure, blood sugar, etc), andclusters of these represent (by definition)a disease. Since deviations are defined interms of norm ative ranges that are emp iri-cally derived, diseases are strictly speak-ing not univeral entities, but instead, tiedto specific spatiotemporal frames. Stateddifferently, m an adap ts to distinct ecolog-ical niches, and since normative ranges ofthe various biological variables are framedin terms of such ecologically based adjust-ments, it follows that disease (clusters ofdeviations in biological variables) are rela-t ive and population-based "enti t ies."

Psychiat r ic diseases are problemat icprecisely because their relevant indicatorsare rooted in or impinge directly upon so-cial conduc t (8). By and large, such thingsas x-ray shadows and/or the presence ofprotein in o ne's urine are neither reflectedin social behavior nor do they reflect ona person's identity. Consequently, beingtold one has pneumonia or chronic glo-merolorephritis is not, generally speaking,discrediting to the person. It is the directlink that psychiatric diseases have withsocial behavior that make for the specialpsychological an d social problem s that arecreated by psych iatric labeling. Stated dif-ferently, the fact that general-medical dis-ease indicators are ordinarily divorced

from social behavior leads physicians andpersons to use disease labels in suc h a fash-ion that they usually prove socially in-consequential; when these labels are psy-chiatric ones, however, they lead to socialproblems because the labels devolve frombehavior and reflect upon one's identity.There are exc eptions to this matter of dis-ease labels, and psychiatry is of course notunique in this regard (9). Nevertheless,despite these considerationswhich es-sentially involve the social consequencesof psychiatric labelingas logical entities,psychiatric diseases are formally analo-gous to other medical diseases.

PROBLEMS POSED BY THECULTURAL STUDY OF DEPRESSIONThe Problem of Defining DepressionA reading of the psychiatric literaturediscloses that controversy and problemssurround the definit ion of depression.This paper can be viewed as an attemptto shed some light on this controversy. Wewill suggest later that some logical anddefinitional problems take their form andcontent from ethnocentric assumptions;that is, that they stem from too stronglyrelying on criteria that are tied to our dis-tinctive sociocultural frame of reference.In fact, although a great deal of researchhas been directed to cultural aspects of de-

pression, we will indicate that much ofthis research, and especially the infer-ences that the research findings generate,are misdi rected and contaminated byWestern c ultural biases. These biases , it isto be emphasized, obfuscate matters andretard the articulation of a perspective thatcould be more productive for the under-standing of depression. In order to exposethe nature of these biases, it will do wellto init ial ly hand le "dep ression " as thoughit were a purely linguistic entity. In this378 Psychosomatic Medicine Vol. 36, No. 5 (September-October 1974)


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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONlight, we will for the moment ignore thevarious processes and manifestations thatgive "depression" its meaningie, wewill neglect the semantic properties of thistermand concentrate instead on moreabstract or generic considerations (10-12).From such an abstract and essentiallylogical perspective we can say that "de-pression" is a term that signifies a set ofrelated organismic processes that lead to,produce or are reflected in a set of nega-tive changes or deviations in the way theorganism functions (eg, physiologically,socially, psychologically, etc). Defined inthis fashion "depression" is a term, muchlike any other medical term that signifiesa disease state. The nature of the processesthat define and constitute "depression"are left unspecified, and likewise the setof related deviations or dysfunctions thatreflect these processes are not addressedin any specific manner. We mayparenthetically note that from observa-tions of ill persons in Western cultures,physicians and psychiatrists (who them-selves are of this same culture) have sin-gled out "emotional changes" as centralmanifestations of "depression." Moreover,of these types of changes, those that con-note a sense of self-denigration, hopeless-ness and despair have been raised to thestatus of paradigmatic indicators of thedisease. Other indicators of the disease sig-nified "depression" (eg, physiologic,behavioral, cognitive, etc) are seen as bothreflecting and elaborating upon the emo-tional ones.For expository purposes we may labelthose dysfunctions that constitute ourWestern interpretation or view of this en-tity Di, D^ Dn, keeping in mindthat from a generic and formal standpointthe changes Aof this entity could betermed Di D2 D*, where: D = dys-functions or deviations seen in "depres-sion," W = characterizations of these dys-

functions based upon Western culturalsymbols, and A = an abstract culture-freecharacterization. We can in this regard in-troduce the term Dj, letting it signify dys-functions that are distinctive of that whichwe label as "depression" in a mythicalculture X.In thinking about "depression," it w illprove instructive to isolate on semanticalgrounds four separate issues. The first,wewill stipulate, represents the underlyingmicroleveled organismic processes thatare characteristic of that which is labeledas "depression" (eg, neurochemicalchanges). The second one involves themacrolevel organismic changes that con-stitute the disfunctions that are character-istic of "depression" (eg, emotionalchanges, behavioral changes). For pur-poses of brevity, let us term these behavi-oral disfunctions. Earlier, one and twowere referred to together as Df, with Astanding for a culture-free characteriza-tion. Such disfunctions, then, are ideal-ized and pure in the sense that we viewthem as not yet realized. From a certainstandpoint, of course, this consideration ispurely theoretical since what we designateas "depressions" can only exist in relationto a distinctive sociocultural frame. Wenevertheless draw attention to this levelof analysis for heuristic reasons. The rela-tions between events and phenomena inone as compared to two above should notbe seen as causal. For example, it oftenproves awkward to say that bodilychanges cause emotions or behavior, orvice versa (13,14). Rather, the domainsshould be seen as logically independentand relations between them conceived ofas mappings or transformations. Thus, afunctional relationship may be said to ex-ist across the domains though the natureof this function is unspecified.The third issue to be taken note of inour semantical analysis of "depression"

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HORACIO FABREGA, JR.involves the behavioral dysfunctions sig-nified by the term as these are expressedin a particular culture. In our culture, forexample, these are represented by crying,feeling listless, reporting and otherwiseshowing anergia, etc. We earlier labeledthese Di. Distinctive and culturallymarked behaviors, then, are what we havein mind here. The fourth and last consid-eration that relates intimately to the thirdinvolves the meaning that is given in aparticular culture to the dysfunctions of"depression" as these are expressed in theculture (eg, terms such as "sadness,""helplessness," "weakness," etc, may beused). Item four, which is purely sym-bolic, is thus represented by the labels andterms that give meaning to those behavi-oral dysfunctions that constitute "depres-sion" in a given culture. These matters aredepicted in Fig. 1. It needs to be empha-sized here that from a certain philosophic

perspective, behavioral changes that oneobserves have the meaning and signifi-cance that are contained in the very labelsused to describe them (15). Stated differ-ently, behaviors have no meaning outsidethe very language we use in description.This is the same as saying, for example,that at the level of human awareness, bio-logic processes such as raw sensationscannot be identified. What are identifiedinstead are perceptions or private repre-sentations, and these already contain atheoretical or conceptual element reflectedin the very terms we use to signify them.It is for this reason that in an empiricalsense, item three can be distinguishedfrom item four only with difficulty, if atall.In the light of issues discussed above,we may point to four connecting links thatneed to be taken into account in under-standing that which we term "depres-

Physical EnvironmentSocial and CulturalGenetic Complexes

OrganismicProcesses thattake place withinan individual thatare distinctiveof Depression (D R)(Defining character-istics ofDepression?)

BehavithdjDe(nts

at ratinprespfintics

oraeflctisioinpof

1 Changesect processesve of

iDepression?)

t Depression, asxpreased in a Cultur.haracterized in the

Fig. 1

How the Organismicdistinctive of De-expregsed in agiven Culture (D*,

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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONsion." These are also labeled in Fig. 1.Connecting link (a) involves how thechanges of "depression" are produced (ie,"causal factors" and processes). Linkage(b) how the microlevel processes (eg,neurochemical changes) become trans-formed into the macrolevel processes (eg,idealized behavior dysfunctions that aredistinctive of "depression"). Linkage (c)signifies the process by which such poten-tial behavioral dysfunctions get encodedinto a culturally specific form. Finally, lin-kage (d) signifies the relations that obtainbetween culturally structured phenomena(eg, symbolic behaviors) and culturallyspecific symbols (eg, linguistic terms).

Is Depression Foundin All Cultures?(The Problem of Universality)Empiricai Findings. An enduringpreoccupation of persons who work in thefields of social and cultural psychiatrycenters around the question of whetherthe disease depression "exists" in othercultures. The prevalence of depression inAfrica may be used as an illustration ofthe problems just discussed (16). Al-though there are exceptions, the literatureindicates that during the Colonial Era(1890-1956) instances of depression (of apsychotic nature) were either absent or

rare, less intense and shorter in durationif present, rarely included self-castigationon the part of the diagnosed person and,lastly, seemed to rarely involve suicide.These generalizations are based on datadrawn from mental hosp itals. Various rea-sons have been offered for these allegedfindings: One set of these involves the va-lidity of the findings; for example, thathospitalized patients constitute a poor andbiased sample, that what an external ob-server would judge as an instance of de-

pression is not differentiated in any sig-nificantly medical way by Africans andhence cannot be brought to the attentionof medical personnel, etc. Another set ofreasons for the alleged absence of depres-sion in Africa assumes the validity of thereports and involves psychosocial factorsbelieved to play a role in the etiology ofdepression: for example, that the extendedfamily and funerary rules "protect" per-sons who are mourning over object loss;that Africans make extensive .use of thedefense mechanism projection and conse-quently cannot develop guilt; that amongAfricans a clan as opposed to personal su-perego prevails and that such a form ofpsychosocial control also eliminates a nec-essary condition for depressive symptoma-tology, etc.Reports suggest that during the era ofIndependence (1957-onwards) instancesof depression were not only not rare butactually common. The reasons for theincrement in the prevalence of depressionare believed to be that the newer observa-tions took place in so-called "open" hos-pital settings as well as in indigenoustreatment centers, and that researcherswere now relying on newer concepts ofdepression that included somatic preoccu-pations as indicators of the disease. Asstated earlier, persons showing evidenceof depression are often not judged as illby their co-members, but if they are, theyare more likely to be treated in indigenouscenters where psychiatrists had nowturned for observations. Furthermore,researchers were now using the label de-pression for states that earlier would havebeen classified as "neurasthenia" or "hy-pochondriasis." Given these consid-erations (equivocal findings and conflict-ing methods of procedure) and the ab-sence of suitable field epidemiologicalstudies, one is forced to conclude that wedo not know whether in fact depression

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HORACIO FABREGA, JR.is as prevalent in Africa as it is in Westernnations.Even when depression is studied in set-tings that share a common language andset of traditions the problem of compara-tive epidem iology of this disease is a per-plexing one and seen to involve a numberof theoretical issues. Thus, a long stand-ing finding in studies that compare ratesof hospitalization for psychiatric diseasein England and in the United States hasbeen the differential rates observed formanic-depressive psychosis and schizo-phrenia. Consistently, investigators haveuncovered h igher ra t es for manic-depressive psychosis and lower ones forschizophrenia in England (17). For rea-sons outl ined elsewhere in this paper,hospital rate differentials are difficult tointerpret. One way of explaining them isin terms of differences in the behavior ofpsychiatrists as opposed to those of thepatients. The rate differential, in otherwords, could be due to differences in theway British and U.S. psychiatrists con-strue and use concepts such as "schizo-phrenia" and "manic-depressive." TheU.S./U.K. Diagn ostic Project was a ddr ess edin part to answer just this type of question(17). It involved the training of a smallgroup of project psychiatrists in the useof a standard interviewthe present StateExamination developed by John Wing andhis colleagues in Londonand involvedthe evaluation and diagnosis by these psy-chiatrists of a group of recently hospital-ized patients in New York and another inLondon (18). In each locality, the diag-noses rende red by the Project psy chiatristson a group of patients we re system aticallycompared with the diagnoses rendered bythe regular hospital psychiatrists on thesame group of patients. Hospital diagnos-tic profiles conformed to expectations,with British personnel rendering a higherfrequency of manic-depressive and a low-

er one of schizophrenia when comparedto the Am erican. The Project psy chiatrists,on the other hand, produced diagnosticprofiles in each of the two settings thatwere in closer agreement, althoug h across-natio n differences of a sma ller sort stillprevailed, suggesting to the researchersthat actual patient differences may haveexisted. At any rate, the elimination ofsignificant amo unts of across-nation varia-tion indicates that much of the differenceone observes in international comparisonsmay stem from differences in the way thecorresponding diseases are construed bythe psychiatrists. Thus, when relativelystandard instruments are used by a homo-geneous and rigorously trained group ofpsychiatrists, the actual diagnoses ren-dered on patients from allegedly contrast-ing populations tend to more closely re-semble each other (20,21).

Another approach to evaluating thissame possibility that cross-national differ-ences in rates of hospitalized patientsstem from behavioral differences of psy-chiatrists involved the audio-v isual tapin gof patient interviews and the subsequentuse of the tapes as data that psychiatristsin the U.S. and U.K. used to render diag-noses. In one of diese studies, examiningpsychiatrists were furnished additionalbackground data on the patients. Despitethe fact that U.S. and U.K. psychiatristswere evaluating the "same" patients, as itwere, across-nation differences in propor-tion of depression still prevailed and con-formed to expec tations (22). Th e otherstudy, which used only the audio-visualtapes and did not furnish psychiatristsbackground information, also producedsignificant across-nation differences in useof psychot ic diagnost ic categories asanticipated. This again indicated basicdifferences in concept meaning and sug-gested to the investigators that serious res-traint be placed on the interpretation of382 Psychosomatic Med icine V ol. 36, N o. 5 (September-October 1974)


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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONdifferences in psychiatric disease ratescross-culturally (23). Katz has conducteda similar series of studies and concludedthat perhaps basic differences in the waypsychiatrists perceive and interpre t behav-ior itself (in addition to differences in theway psych iatric concepts are used) may bea factor explaining cross-national differ-ences in psychiatric disease rates (24). Itgoes without saying, of course, that ratedifferences such as these must ultimatelybe traced to social and cultural differencesin the way the psychiatrists are encultur-ated and socialized, both as members oftheir respective social units and profes-sional groups.Comment. How may we characterizethese approaches to the study of "depres-sion" in other cultures? We can say thatresearchers are using as a model of "de-pression" those behavioral changes thatwe in Western-influenced cultures believeare paradigmatic indicators of "depres-sion." In other words, they are using thevarious D as the bases for determiningwhether "depressions" exist in other cul-tures. If all of the organismic changes thatwe have come to associate with "depres-sion" are shown to be present in a mem-ber of a particular culture (eg, an individ-ual with sadness, guilt, anergia, etc), thenit is said that "depression" exists in thatculture. When only some of these changesare observed, or when the changes ob-served are believed to be analogous (ie,similar, culturally "equivalent") to thosefound in Western cultures, then it is saidthat "depres sion" assumes a somewhat al-tered form. If the changes observed in agiven individual (who may or may not bejudged as sick in the culture) cannot beequated with those changes we associatewith "depression," then he is said not tohave "d epr essio n." And finally, if no indi-viduals are ever found who show theWestern changes or indicators of "depres-

sion," then "d epres sion" is said not to ex-ist in that culture. In short, it should beobvious that definitions and essential fea-tures characterizing what might be calledthe "Western version of depression" aretaken as the true or real indications of"depression"; using these as a yardstick,attempts are made to diagnose "depres-sion" in other cultures. This is what wasmeant when it was said earlier that ethno-centric assump tions (ie, biases) unde rliethe cross-cultural stud y of psyc hiatric dis-ease.Given the way in which psychiatry hasevolved, we can with the advantages ofhindsight understand and explain how itwas that these biases came to underlie thestudy of depression. Since ancient times,the disease depression (then called melan-cholia) has assu med a more or less distinc-tive (Western) form that involved emo-tional and behavioral changes of a typewe now view as "classic" or pathogno-monic (1,2). Sadness, despair, helpless-ness and bodily preoccupations of varioussorts, in other words, have consistentlybeen a part of what depression, ie, melan-cholia, meant. It is no surprise, then, thatthese types of changes are still seen todayas indicators of depression, a disease cod-ified by Kraepelin on the model providedhim by ancients. The behavioral dysfunc-tions that we have co me to view as classicof depression have maintained a measureof specificity and interconnection in ourWestern culture over the years. We mayhave brought greater refinement to thedescriptions of these changes, but thatthey partake of the same general form andsemantic markings cannot be debated.We should em phasize that since ancienttimes, depression (or melancholia) has as-sumed a characterization and interpreta-tion that wholistically oriented psychia-trists now claim is exemplary of this dis-ease; namely, that of judging it a psycho-

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HORACIO FABREGA, JR.biological entity. Behavioral changes thatwe of Western culture associate with bothof the separate domains of mind and bodyhave consistently been associated withand been seen as typical of depression.We have only to be reminded that theterm melancholia literally means blackbile; that its meaning is tied to humoralnotions used to explain bodily and tem-peramental differences and that such hu-moral notions in time gave way to atheory of personality and of disease. Anancient version of our modern and refinedunified view of disease is bound togetherwith the notions of the various humors,and depression, ie, melancholia hasalways been linked in a literal sense withsuch ideas (25).

A research question that inevitablyarises can be phrased as follows: what isthe nature of the linkage that exists be-tween, on the one hand, those micro andmacro organismic changes that we haveidentified with "depression" (ie, roughlyDA)and the behavioral dysfunctions thatwe of Western-influenced cultures havecome to judge as pathognomonic of "de-pression" (ie.Dw). Stated differently, ifthat which is signified by the term "de-pression" is a psychobiologic entity, thenwhy and how are the underlyingpsychobiologic changes of "depression"transformed into the form that we see andrecognize in our everyday clinical work?Similarly, we may ask how do thepsychobiologic changes of "depression"get transformed into other cultural guises(ie, Df) ? Why, for example, do the organis-mic changes (ie, the Df) of "depression"lead to sadness-despair in our culture?What might these same changes lead toor produce in other cultures? It should beclear that in terms of the perspective wehave adopted here, this amounts to inquir-ing into the function and mechanism of

elemental symbolic categories and prem-ises that structure behavior, feeling, cogni-tion, etc, in individualsthe very roots ofwhere biology and culture meet. One as-sumes, in other words, that man consid-ered biologically (ie, chemically, neuro-physiologically, anatomically, etc) is thesame everywhere, and that alterations inhis biology are likewise similar, ie, in-volve identical mechanisms and pro-cesses. However, how these biologicalchanges become transformed into variousspecific behaviors and why they assumethe particular expression that they do indistinctive cultures is dependent on fun-damental symbolic categories that struc-ture and encode behavior. Let us elaborateon this point.In Western culture, as we have said,sadness and despair are emotional tonesand behavioral dispositions that are

linked with and come to express those or-ganismic changes that are distinctive of"depression." We have reason to believethat the underlying processes and unitsthat lead to the encoding of these emo-tions in the human face are general uni-versal attributes of man, and an implicitassumption appears to be that the emo-tional experience that signals these facialdisplays are also probably universal a ttri-butes of man, though this of course cannever be proved (26). Stated succinctly,we assume that all members of the humanspecies feel something akin to what weterm sadness and despair, and moreover,express and recognize such moods inothers by means of distinctive facial dis-plays. However, how does this mood cometo be associated with a particular behavi-oral constellation, and why is it that inour culture the resulting changes whenpersistent tend to be judged not only neg-atively but also as a disease? Is there inpoint of fact a universal mechanism that384 Psychosomatic Medic ine V o l. 36 , No. 5 (September-October 1974)


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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONlinks the mood with the behavioral con-stellation in the first place? Is there also,as we tend to assume, something neces-sary about the connection between thesemood-behavioral alterations and the un-derlying organismic changes (D;) that maybe judged as the true significata of theterm "depression"? Might these same un-derlying organismic changes be linkedwith other mood tones or behaviors inother cultures, or might no recognizablemood alteration be associated with the or-ganismic changes of depression? Is theemotion we term despondency or sadnessa necessary feature that is always or usual-ly an outcome of D;? Are there culturallyinvariant behaviors that are always orusually an outcome of D'f ?

We are led to entertain the possibilitythat the underlying organismic changes of"depression" (ie, the denning characteris-tics) may represent alterations in elemen-tal biological mechanisms of man and thehigher primates (27), perhaps disartic-ulated processes involving the conserva-tion of energy as Engel has suggested (28).Persons socialized in various culturesmust be presumed to express thesechanges in various ways. Why we ofWestern-influenced cultures show and feelsadness and despair under these circum-stances may depend on basic symboliccalculi that structure and give meaning toour experience. They are, in short, ourculturally specific way of reflecting suchorganismic changes. We must be preparedto find other culturally specific ways inwhich those elemental changes of "de-pression" could enacted. Thus, the ques-tion underlying empirical inquiries of"depression" in other cultures should notbe: Can we find D D^- D^ in cul-ture X? The question should rather be:What form will Di D2X- Dx take onin this culture? Or, stated differently: How

will the fundamental organismic changesthat define "depression" be enacted in thisculture?Are There Legitimate Questionsto Pursue in Cultural Psychiatry?It may appear that adopting the positionwe have outlined above amounts to theelimination of the field of cross-culturalpsychiatry. After all, if studying "depres-sion" in other cultures using ethnocentricbiases (ie, by searching only for specificdysfunctions associated with "depres-sion" in Western-influenced cultures) iseither fallacious or at least a crude ap-proach, then how is one to go about thissearch? What procedure can be adoptedwhen, it would appear, one literally doesnot know what one is looking for! Firstof all, it should be appreciated that on em-pirical grounds there is nothing wrong

with studying "depression" cross-culturally using the Western model as ayardstick. In a sense, clinicians of any dis-cipline adopt this approach each timethey evaluate any patient, and the proce-dure is the cornerstone of any inductivescience. Using the Western analogue of"depression" as a guidelineas afirstap-proximation, to be refined and modifiedallows the researcher an initial mode ofexploration. It allows him to evaluate theextent to which the various D^preserve anidentity cross-culturally, the extent towhich they interrelate and coalesce withother D i and D* into discernible behavioralsyndromes and by extension the readingor symbolic interpretation given to suchsyndromes in the cultureie, how theyare judged, what interpretation is given tothem, etc. However, rather than losing in-terest or discarding data when certain or-ganismic dysfunctions or deviations (D7)appear in altered formor new ones pf)appear associated with the expectedPsychosomatic M edicine Vo l. 36, No . 5 (September-October 1974) 385


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HORACIO FABREGA, JR.onesthe researcher should strive to ac-curately describe these phenomenological-ly and behaviorally. Rather than saying D;appears masked here, he should say per-haps a new set of D*obtain here, and theseneed to be accurately depicted. It is onlyby way of drawing on many of such cul-tural versions or models of "depression"that a fundamental understanding of whatwe have come to call the disease depres-sion will be achieved.The rationale described above impliesthat cultural psychiatry should preserveboth a descriptive and inductivist base.An extension of the rationale outlined canbe visualized: cultural psychiatristsshould aim to describe and explain thereasons for the prevalence of variousbehavioral syndromes. These syndromesshould be seen as composed of behavioraldeviations, and the syndromes shouldhave a morphology such that they are pat-terned across individualsie, they shouldshow cultural specifity. W hether such be-havioral syndromes are judged as diseasesby members of the culture should be in onesense irrelevant. Psychiatry as here de-fined, is the science that seeks to discoverand explain the regularities in human be-havioral deviations. Whether such syn-dromes constitute disease is purely a so-cial and cultural matterthat is, this de-pends on native rules that assign meaningto the behavioral deviations. Medicine, itshould be remembered, is also a social sci-ence in that it assigns the label disease to aset of selected behavioral regularities thatare disvalued and that society and itsmembers judge should be eliminated orcorrected (7). It cannot be doubted , ofcourse, that psychiatry profits to the extentthat it can also explain why certain be-havioral deviations or syndromes get as-signed the label disease whereas others do

not. In fact, insofar as psychiatry can alsobe defined as the branch of medicine thatseeks to understand and treat psychiatricdisease, it stands to reason that it mustaddress those processes that attend thesingling out of certain behavioral syn-dromes as disease, and especially thereasons for these essentially sociomedicalconsiderations. In this regard, we shouldpoint out that few persons have addressedthis issue in any intensive manner.It will no doubt be appreciated thatwhat we are arguing for at this junctureis for a perspective towards the culturalstudy of "depression" that is essentiallybiocultural as opposed to only sociocul-tural. With regards to that which is sig-nified by the term "depression," weshould strive to articulate its definingcharacteristics in as near a culture-freelanguage as possible. From the frame ofreference adopted in this paper, thismeans that one should strive to uncoverand systematize two interrelated aspectsof "depression": on the one hand, inter-related neurochemical and neurophysio-logic changes that in their totality under-lie behavioral alterations that may show ameasure of specificity across space andtime; and on the other, the abstract andgeneric forms or moulds that set boundson how these behavioral alterations are ac-tually expressed in a culturally contex-tualized form. Both of these may bejudged the significata of the term "depres-sion." It is granted that these neurobiolo-gic categories can only be equated (initial-ly) with the Western behavioral version ormodel of "depression"; nevertheless, thefact that these neurobiologic processesmight be articulated in a language framethat is uncoupled from social behaviormeans that cultural inquiries into the na-ture of "depression" are substantially



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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONaided (7). By means of successive approxi-mations that involve working with bothsociocultural and neurobiologic para-digms, it may be possible to achieve acomprehensive understanding of what thechanges signified by "depression" mean.In the same vein, cultural explorations of"depression" need to be linked with theparadigms of human genetics, populationbiology and medical ecology generally.This means that older approaches charac-teristically associated with the fields ofculture and personality and psychiatricanthropology need to be broadened so asto admit population and other biologicalconsiderations. A reading of the socialscience literature discloses that such a bio-cultural approach is being emphasizedmore arid more (29).

Ultimately, explorations in cultural psy-chiatry will be concerned with identifyingthe mechanisms and processes by meansof which basic neurobiologic happeningsbecome translated into behaviors. Thiswill involve describing, codifying and ex-plaining the workings of the symboliccategories that are at the root of behavioralorganization. These symbolic and mostprobably cognitive categories or maps arewhat structure, form and in essence estab-lish behavioral regularities. It is thesecategories, moreover, that mediate be-tween neurobiology and psychologicaland behavioral changes. What are theforms of these categories, how are they or-ganized and how are they related to theother patterns, values, rules and institu-tional arrangements that make for culturaldistinctiveness ? How and why are behavi-oral syndromes formed? And, given theexistence of such behavioral syndromes,in which cultural groups are they viewedas disease? And, what factors or reasonsmight lead to the viewing of such syn-

dromes as diseases as opposed to some-thing different? These and similar typesof questions, in our estimation, articulatethe proper locus of cultural psychiatry.PROBLEMS POSED BYT H E S O C I A L S T U D YOF DEPRESSIONI N W E S T E R N N A T I O N SHere we examine theoretical problemsthat arise when social aspects of thatwhich we view as the disease depressionare studied in Western nations. We willnot discuss differences in depressivesymptomatology across ethnic groupssince this involves considerations logical-ly equivalent to those already reviewed.Despite the fact that depression will bedealt with generically and as though itsidentity and attributes were more or lessunproblematic, we will see that definition-al and other conceptual difficulties never-theless arise that impinge on and can mis-direct empirical inquiries. These difficul-ties need to be resolved so that investiga-tions can generatefindings hat w ill clari-fy the links that a psychiatric disease suchas depression has with social happenings.Problems Associatedwith Epidemiologic InquiriesIn studying the amount and distributionof a psychiatric disease such as depres-sion, hospital statistics and comparabledata from other mental health facilitieshave limited utility. In a "hard" sense,figures based on hospital statistics can betaken to reveal little but the clinical-administrative policies of the particularfacility in questiontheir diagnostic hab-its, as it were. Such figures have been usedto make general and essentially imprecise

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HORACIO FABREGA, JR.inferences about the attitudes, habits andsocial conditions of the respective popula-tion groups. For example, given certainhospitalization rates, one may be led toinfer that groups do or do not use hospi-tals, or that they are more likely thanother groups to turn to hospitals. Alterna-tively, one can say that a particular groupmay or may not be more tolerant of de-viant behaviors than another (ie, with hos-pitalization rates being taken as a measureof the exclusion of deviants) or, finally,that the group may have a different levelor amount of psychiatric problems. Theseand, no doubt, other inferences can bedrawn from epidemiologic studies thatdraw on hospital statistics. When com-bined with data from various sources andwhich has been collected under differentconditions, hospi-il rates can be used toanswer limited questions as Kramer hasalready indicated (17).It may be believed that field studies of-fer the solution to the problem of estab-lishing meaningful rates or prevalence orincidence of a disease such as depression.However, given the nature of the theoreti-cal and methodological problems sur-rounding psychiatric epidemiology, verylittle in the way of cogent and revealinggeneralizations can be drawn from fieldstudies purporting to measure the prev-alence and incidence of psychiatric dis-ease. In psychiatry one finds fundamentalconceptual problems regarding the defini-tion and meaning of normality, psychopa-thology and disease. In a formal sense onewould say that the "proper" domain ofpsychiatry is poorly bounded; elementalproperties that unambiguously set phe-nomena apart as psychiatric as opposed tothat of other service disciplines are lack-ing. At the same time, current method-ological attempts to measure and establish"caseness" in such field studies

untreated instances of the disease, as itwerecan be faulted on so many accountsthat results of these studies can only beused to draw but limited insights of a tell-ing nature. Furthermore, conceptions ofdepression are currently in such a fluidstate, and understandings of the nature ofdepressive disease(s) so variable, that littlecan be gained by reviewing in detail ear-lier studies that have employed differingand overlapping definitions regarding de-pression. (Issues discussed earlier are ger-mane here.)Ideally, a social epidemiologic inquiryshould begin with a clear analytic defini-tion of a particular disease entity. Thisdefinition should in turn be operational-ized by the development of indicator testsof the d isease. In practice, this means thatthe uncovering of a particular set of indi-cators can be said to constitute necessaryand sufficient conditions for inferring (ie,diagnosing) the disease in question. Themeasurement of the indicators of such adisease should be easily accomplishedand subject to unambiguous interpreta-tion. Studies employing such operationaldefinitions of disease should be conductedusing a bounded social group as a refer-ence population. Field methods and sur-vey analyses are called for, and a probabil-ity sample drawn from the community isevaluated so that both treated and non-treated instantiations of the disease inquestion can be unambiguously marked.Coincident with this, there should be asurvey of the rosters of all in-patient andout-patient facilities that service the groupso that treated instances of the disease canbe verified and/or discovered (in the caseof hospitalized patients). Private psychia-tric and other medical practitionersshould also be consulted. Questioning thelatter becomes critically important in thecase of depressive disease, since patients

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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONso diagnosed, it has been established, arefrequently seen by general practitionersand internists.In general, social epidemiologic studiesthat meet these standards are not common,and conceptual and methodological prob-lems involving how disease is to bemarked contribute importantly to thisstate of affairs. As one may anticipate, so-cial psychiatric epidemiologic studies thatmeet the above standards are rare. A num-ber of field investigators have used arather global definition of psychiatriccaseness, namely, symptom scores derivedfrom questionnaire responses (30,31). Al-though useful for certain purposes, suchmethods are of little value for those inter-ested in evaluating a particular nosolog-ical entity. In these studies, subjects (ie,potential cases) are not interviewed bypsychiatrists. Rather, protocols of inter-views conducted by lay persons and socialscientists are subsequently rated globallyby psychiatrists. In the Leighton studies,symptoms were classified into syndromesand the APA manual was used descrip-tively for this purpose. Consequently, adegree of nosological specificity wasmaintained; however, it still was the casethat rather general questions were used asthe basis of generating data (32,33). Thus,although patients were classified as neu-rotic or psychotic, it is clear that no confi-dence (in a clinical sense) can be placedin this signification. More recent studiesby Dohrenwend have brought to lightsome of the biases and deficiencies ofthese particular types of studies and raisedquestions about the validity of conclu-sions drawn from them (34). He haspointed to the differences in the way thatethnic groups respond to symptom ques-tionnaires ("modes of expressing stress"),to the neglect of contextual factors in theevaluation of symptom responses and to

the fluctuating nature and predictive inac-curacy of such symptom responses. Thereare, to be sure, a number of rather basicproblems associated with the use of suchscores and these need to be discussedbriefly.Symptom questionnaires that are typi-cally used in field psychiatric epidemiol-ogic studies include psychologic and psy-chophysiologic referents. Persons areasked whether they experience such con-ditions as sweaty palms, sadness andtiredness. What is obtained in such stud-ies is a distribution of symptom scores andthese scores are seen almost as linearly re-lated to the issue of psychiatric disabilityand caseness. In some instances, ancillaryinformation about person's social adjust-ment is included. By developing cutoffpoints using similar data obtained onknown psychiatric patients, the investiga-tor infers how many cases exist (and whatare their degrees of disability) in his sam-ple. The comparison group "patients," interms of which cutoff points are framed,is usually heterogenous and includes vari-ous diagnostic types. This rationale fordefining cases in field psychiatric studiesharbors the following implicit assump-tions: since psychiatric disorders arehandled in terms of symptoms, they mustall be of a similar behavior, psychologicor biologic type; psychiatric diseases allbear equally on a notion of psychiatric sta-tus or "patienthood," and furthermore canall be graded comparably in this regardand as to degree of associated disability;each instanciation of a disease can beplaced unproblematically on a continuumof disability for that disease; and lastlyany and all symptom scores (regardless ofbasis) can be evaluated similarly, whichmeans that disease types and their asso-ciated continua of disability are fused. Ithardly appears necessary to emphasize

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HORACIO FABREGA, JR.here that all of these assumptions are veryquestionable and conflict strongly with theclassic nosologic view of psychiatric dis-ease. These criticisms should thus not beseen as directed at the psychiatric epidem-iologic approach per se, but rather at thetendency to uncautiously generalize aboutmatters of psychiatric nosology using re-sults from field epidemiologic studieswherein symptom levels constitute thekey dependent variables.

Recent studies of ethnic differences indepression bring into focus problems in-volving the epidemiology of this disease.This work was carried out in a multi-ethnic setting, namely Hawaii, and in-volved studying psychiatric in-patientsfrom various ethnic groups (35-37). Thebehavior of these patients at two pointsin time was compared. In the hospital,psychiatric personnel applied Westernclinical criteria dealing with the pheno-menology of illness, whereas in the com-munity lay persons (significant others)who had had contact with the patientprior to admission completed question-naires about the patient's social behavior.These latter questionnaires inquired abouta variety of clinically relevant social be-haviors, and these behaviors were de-scribed in every-day language. The actualfindings in these studies don't need to bementioned.Significant is the fact that communitynorms and standards vis a vis deviant be-haviors were used as a background againstwhich the clinical behavior of hospital-ized patients was evaluated, for it is thesenorms that "force" or prompt hospitaliza-tion. Let us elaborate upon this point. Wewill assume that members of ethnic groupX (or for that matter culture X) judge aparticular set of behaviors as normal, ex-pected or appropriate and another set asdeviant (DxvsD*l. A similar formulation

v n a'

applied to another group Y would yieldbehaviors labeled Dya and DJJ, respectively.Now, it is behaviors D^ and Dyd that leadthe patient or those responsible for himto seek medical care or hospitalization.Why this is the case requires explanationand involves probing the traditions, val-ues and behavioral rules of the respectivegroup. Explaining the presence of the be-haviors in the first place involves socio-cultural as well as genetic and other bio-logical factors. The behaviors Dd and Blmay not, of course, be parallel and in factmay include segments that the contrastinggroup judges as "normal." Such sociallydefined "normal" behaviors can, if viewedbiomedically, be judged as symptomaticor pathological. If this discrepancy is ob-served, then one is led to inquire in to cul-tural factors for an explanation.

To summarize, in any one social group,one is led to posit a series of classes ordimensions that may be used to classifysocial behaviors. These categories may bedrawn by the observer from without, andthey may or may not be consistent withcategories that members of the groupthemselves use or follow. Moreover, thesocial behaviors, which are symbolicallyframed in a culturally distinctive manner,are empirically distributed in variousways. Members of the group segment,partition or grade such behaviors in termsof appropriateness, just as clinicians arewont to draw on the behaviors in evaluat-ing psychiatric status. These two ways oflooking at social behaviors are logicallyindependent (7). Explaining the reasonswhy behavior is judged inappropriate inthe group requires going into social cul-ture considerations, although the bases forthe behavior may rest heavily on noncul-tural factors. Distributions of behaviors (ofa certain type) along the continuum of ap-propriateness need to be compared across

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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONpopulation groups. It is implicit in the re-searcher's formulation that the judgmentsand labels placed on such behaviors (eg,vis a vis deviance) and the actions impliedby these labels will be substantially differ-ent across ethnic groups or cultures; suchdifferences, moreover, will require a cul-tural explanation. Given these considera-tions, it should be clear why comparativestudies based on hospitalized patients areof limited value in understanding genericquestions about a disease such as depres-sion: such'comparisons merely yield dataon a certain subset of patients with a giv-en disease, namely, those judged (forwhatever reason) as problematic in theirrespective social groups.Problems Involving the Social Precip-itants of Depression. The question ofwhether social factors play a role inprecipitating depression raises several is-sues. One of these involves the definitionof stress (38). We shall use the term situa-tion, precipitants or even stressors to referto environmental events or circumstances 'that are potentially problematic to theindividual; the term "stress" will be usedto signify the presumed internal organis-mic changes that may result from such sit-uations and that can potentially interferewith the person's adjustment and adapta-tion. A reading of the social psychiatricliterature will show that researchers donot ordinarily separate between these twocategories conceptually, let alone empiri-cally. Stressors, in short, are usually as-sumed a priori to produce stress and may,in fact, be used to signify stress. Con-versely, the mere presence of depressionis often taken to indicate that stress hasin fact occurred. What is actually demon-strated, then, is simply an association be-tween the clustering of stressors in per-sons who are also classified as showingdepression. The inference is that the asso-

ciation is causal, though this cannot beproved except by psychological analysesor by using much more refined methods.It should be appreciated that the prob-lem of evaluating empirically the in-fluence of social stressors in depressivedisease is confounded with the problemof what depression "is" and how it shouldbe defined. For example, it has beenshown that in so-called grief reactions oneobserves many of the phenomenologic fea-tures of the depressive state (39). Distin-guishing between a grief reaction and adepression is clearly a difficult empiricalproblem and rests on criteria of definition.Any association between stressors and de-pression will differ depending on the ex-tent to which purely descriptive factors (tothe exclusion of situational ones) affectdiagnostic criteria of depression. Alongthe same lines, a clinical truism is thatstrong affective reactions of a depressivesort occur as "stages" in pre-existing"psychiatric" disturbances such as alco-holism, anxiety neurosis and drug intoxi-cation. Despite the fact that these "depres-sions" may include typical motoric andbehavioral features viewed by many asdiagnostic of depressive disease, argu-ments have been marshalled to the effectthat such "secondary" depressions shouldbe excluded from studies aimed at carefulevaluation of social influences on the on-set and course of a presumably separateentity, so-called primary depressions (6).It certainly is the case that the line be-tween primary and secondary depressionscan often not be precisely drawn empiri-cally using phenomenologic criteria;furthermore, the causal linkages amongthe associated problems seen in secondarydepressions can be interpreted differently,eg, drug abuse can often be seen as a wayof coping with "primary" depressive feel-ings. These problems, of course, place an

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HORACIO FABREGA, JR.empirical burden on the researcher. Onemust grant that grief reactions and mostso-called secondary depressions appearedtied logically to social circumstances;however, if they are both totally excludedfrom a category depression, then em piricalinquiries into the influence of "socialstressors" on depression are indeed some-what suspect if one does not have defini-tional criteria that are independent of so-cial circumstanc es and also do not includ esocial behavior. It is difficult to supporta strategy for evaluating social factors ina disease if potentially relevant ones arealready being used indirectly to frame thedefinit ion of what is being evaluated,particularly so if rem aining definitionalcriteria also bear on social matters. (Seebelow and next section.) For this samereason, one cannot allow a concept "en do-genous depre ssion" to depend exclusivelyon the inability of a clinician to uncovera "clear " precipitating factor. In sum mary,one can note that how o ne defines depres-sion will have an important influence onempirical attempts to measure the role ofsocial stressors.

Events and si tuations we may termstressors and that are related to the socialplacement of the person may precede theonset of depression, in which case theycould be given a causal role. Howev er, de-ciding when a disease "begins" is a verydifficult matter. Since a person who isdeveloping a depression can be expectedto show changes in social behavior andperformance (see subsequ ent section), onemus t assume that interpersonal difficultiesof various sorts are more likely (eg, lossof job, marital discord) so that what in astudy app ears as a potential " cau se" of de-pression may in fact represent a conse-quence. Deciding between these alterna-tives again involves matters of definitionand reflects directly a central problem of

social psychiatric inquiries: the attempt toestablish independence between, on theone hand , social events involving a personthat both affect and reflect on psycholog-ical status, and, on the other, psychiatricdisease that is defined on the basis ofpsychological status. A related prob lem isdeciding on the length of the time intervalpreceeding the onset of disease that onewill allow "stressors" to occupy. This in-terval will depend on the investigatorsmodel of how the disease develops. Thisquestion of etiology brings in once againthe issue of the definition of depression.The role of hospitalization in compli-cating the evaluation of social stressors inthe onset of depress ion c annot be overesti-mated. The compl icat ion produced byhospitalization in this evaluation is simi-lar to the role hospitalization plays in theinterpretation of social epidemiologicalfindings. Since patients who are classifiedas depressive ordinarily are selected andinterviewed in hospitals, so called stres-sors tend to be evaluated in relation to de-pression and often, inadvertently, in rela-tion to the issue of hospitalization itself.Obviously, few psychiatric diseases beginwith hospi tal izat ion, and furthermore,those stressors that antedate hospitaliza-tion may not necessarily be the same asthose that antedate the onset of depressivedisease. The question of the timing of thestress is obviously all importan t. How ever,the issue of hospitalization is problematicin still another way. Even though investi-gators may be careful to interview aboutstressful situations using onset of depres-sion and not hospitalization as the pointof focus, the fact that the sample of de-pressives is usually formed in the ho spitalmeans tha t some bias was probably operat-ing neve rtheless. Persons who seek (or arebrought in for) formal care may be theones who are more pliable and who are



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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONcharacterized by greater responsiveness toand trust in the social system. These fac-tors, in turn, may mean that they showa differential vulnerability to so-called so-cial precipitants. The findings of Morrisonand Hudgens who evaluated the influenceof a number of life events in affective dis-orders using hospitalized m edical and sur-gical patients as controls were notable pre-cisely becaus e they failed to turn u p strik-ing differences (40,41). Patien ts classifiedas having an affective disorder, whencompared to the controls, only showedmore frequent changes of residence andreported interpersonal discord during theyear prior to admission, but this wasusua lly after the disease had becom e man-ifest. It is possible that hospitalization,whic h all patients shared , was a factor thatobscured the differential role of stressorsin the onset of affective disorder. All pa-tients, in other words, may have been se-lected in terms of their general responsiv-ity to social influences symbolized in thisinstance by their readiness to turn to thehospital. In addition, of course, the factthat the control group was composed ofpersons showing disease of various typesfurther complicates matters. A large bodyof research p oints to the imp ortanc e of so-cial stressors in the onset of a number ofdiseases not just the so-called psychiatricones (42). In short , since persons whowere placed in the categories depressiveor "co ntr ol" may both have been "af-fected" by the social stressors, any uniq ueinfluences tied to the disease depressionwou ld hav e been obscured. It is, of course,desirable to compare how stressors affectvarious types of disease. However, an al-together different design is required if thisproblem, as well as the one involving so-cial stressors and depression, are to beclarified.In summary, a clear and unambiguous

answer to the question of the influence ofenvironmental factors on the onset of de-pression would seem to require first theavailability of a definition that is anchoredin unproblematic indicators of this dis-ease. One must then uncover by means offield studies persons showing untreated aswell as treated instanciations of "depres-sion." These persons must then be syste-matically com pared, in terms of frequencyof "social stressors" that antedated thedisease, with subjects who are nondepres-sives but ill and also with others who arenot ill at all, all of whom are drawn fromthe roster of comm unity residen ts. Ill per-sons, both depressives and nondepres-sives, should be classified as to whetherthey are or are not in treatment. In short,in order to determine whether socialprecipitants play a unique role in the on-set of depression, one must establish thatany association that exists between de-pression an d the clustering of such pr ecip-itants does no t result from (1) rand om fac-tors that also affect normals, (2) selectivefactors associated with treatment and (3)effects attributable to the general categoryillness.

Additional Problems Posed by SocialBehaviors of Depressives. How d epress ioninfluences social performance ha s been th efocus of a great deal of research recently.Terms such as social performanc e and alsosocial disability (43) are used to signifyho w persons function in the social system,ie , how well they meet role obligations.Since the very indicators of depres sion re-fer to (or are derived from inferen cesabout) social behaviors, an evaluation ofthe social performance of depressives in-volves matters of definition raised earlier.We saw, for exa mple, that th e question ofthe comparative prevalence of depressioninvolved the matter of how depressionmight be "expressed" in contrasting eth-

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HORACIO FABRECA, JR.nic and cultural communities; this ob-viously requires the appraisal of whatpasses as normal and abnormal social be-havior. One may assume that an instanceof depression is associated with specificneurochemical changes. It is still the case,however, that these changes, if not"caused" by conflicts in role obligations,are nevertheless likely to be observed inpersons showing difficulties in the perfor-mance of social roles. Empirically, then,fundamental changes of depression (thesignificata mentioned earlier) are probablycorrelated with changes in social behav-ior. At the same time, one must recall thatit is only by being directed to persons whomay show role difficulties and then by be-ing able to demonstrate these that the in-vestigator or c linician is likely to diagnosedepression. In short, built into the defini-tion of what depression is and its identifi-cation onefindsa form of indeterminancygrowing out of the direct linkage the dis-ease has with social behavior.

The excellent series of papers con-ducted by Paykel and his associates maybe used as illustrations of how the socialbehaviors of depressives have been inves-tigated (44,45). Drawing on items fromearlier scales, these workers developed aSocial Adjustment Scale (SAS). The itemsof this scale could be ordered into eitherof two sets or classes of social behaviors,termed by them role areas (eg, work, par-ental, etc) and qualitative (eg, behaviorperformance, feelings and satisfactions,etc). It is to be emphasized that these twoclassifications of social behavior were notindependent, so that, for example, itemsreflecting leisure role behavior could alsobe distributed into the various qualitativegroupings. Using the SAS, three patternsof social performance scores were ob-tained that included the two already de-scribed (role area and qualitative) and an

empirical one derived from factor ana-lysis. The SAS was administered to 40 fe-males showing a primary depressive disor-der; 40 female residents of the same areaas the patients served as controls. Interest-ing differences were reported. As can beanticipated, depressed females generallytended to score lower in most role areasand in most aspects of role behaviors. De-pressed housewives scored particularlylower in instrumental role behaviors. De-pressed women who worked outside thehome, on the other hand, were only slight-ly impaired in this domain, although theydid report considerable distress, frictionand disinterest associated with social de-mands. Interestingly, although depressedwomen reported less interest in six, fre-quency of sexual relations with spouse didnot differ markedly. It should be empha-sized that it was in the expressive intra-household role activities that depressedwomen showed greatest impairment.

The design of this study, like those ofrelated ones involving the social function-ing of depressives, does not permit estab-lishing causal priorities, so that one can-not establish whether depression led torole difficulties or vice versa. Such stud-ies, furthermore, point to a related dilem-ma that confronts one evaluating socialaspects of any psychiatric disease: thetendency of persons classified as de-pressed to more frequently offer discredit-ing reports about social performance. Per-sons that are hurting and experiencingdistress and dissatisfaction can be ex-pected to more frequently solicit care andbe counted in such studies as patients;consequently, any appraisals and evalua-tions of their behavior that they them-selves volunteer will naturally reflect suchsociophenomenologic features. Theiractual behavior (ie, "objective," if indeedthis category has any meaning) may not



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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONnecessarily indicate the presumed impair-ment that the subjective report suggests,although short of direct observation theclinician has no way of evaluating this.Evaluating the social behavior of a personas such behavior is perceived by signifi-cant others may avoid this self-reportingbias. However, this approach introducesan additional problem stemming from theobserver's own view of and feeling towardthe patient. Indeed, one may be led toquestion the meaning and usefulness ofmaking diagnostic impressions and/orbehavioral evaluations with regards to aparticular person on the basis of reportsthat are proffered by others who are, soto speak, parties to any "disturbed behav-iors" that may prevail. It should be clearthat this dilemma, like the one raised ear-lier involving the indeterminancy of de-pression, is inevitable given the episte-melogical nature of psychiatric diseaseand human behavior. The "data" of psy-chiatry are embedded in social relationsand partake of its logic and rationale, andthe attempt to measure or evaluate suchbehavior on an independent basis raisesepistemelogical questions.We have so far seen that the social be-haviors of depressives affect evaluation ofprecipitants in this disease as well as thequestion of how depressives function.There is a related problem, namely, thatof when, how and why an instance of de-pression terminates. Problems posed bythe attempt to evaluate the duration of de-pression are thus involved. Clearly,considerations involving the beginningsof depression also apply logically to thatof termination, but to avoid obvious re-dundancy these will not be discussed. In-stead, we will deal with a similar butstrictly speaking separate issue, and thatinvolves the issue of how secondary sociallabeling may retard the resolution of de-

pressive disease and possibly even maskits "true" end point.Social scientists have graphicallypointed out how deviations in the perfor-mance of basic social roles come to beviewed as abnormal and as possible indi-cations that the individual is not well or"mentally ill." Such primary social label-ing, which is very much associated withthe internal organismic processes that leadto the development of disease, has beenwell discussed in the literature (46).Secondary social labeling, however, oc-curs after an individual already shows thecharacteristic evidence of disease, is diag-nosed by relevant medical personnel andis exposed to psychiatric treatment. Ourclaim here is simply that by viewing anindividual as still sick, by continuing tooffer treatment and by recommending andexpecting further psychiatric contactsmental health personnel may unwittinglybe masking or concealing when an in-stance of depression ends. Natural endpoints of the depressive process may bemissed, or remnants of the process nur-tured and reinforced. The result is thesame, the unnecessary prolongation oftreatment and an implicit communicationto the patient that he is still sick. Stateddifferently, either by aggressive, authori-tarian or intensive involvements such per-sonnel may frighten and literally coercepatients into continued treatment. Clearly,many depressive patients by definitiondemonstrate passivity, a sense of helpless-ness, a need for positive reinforcement, alack of inner directedness, etc., and turnto psychiatric personnel in the hope of ob-taining a "cure." Thus, what from onestandpoint appear as typical indicators ofdepression, from another can be viewedas a set of compliant behaviors that char-acteristically form a part of the so-calledsick role. What is part of a disease fits in

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HORACIO FABREGA, JR.logically with what is expected of a pa-tient, and a continuation of such a patientstatus may pass as disease when in factthe underlying organismic changes thatset the disease in motion are no longer inevidence.A consequence of the above, quite ob-viously, is that the duration of an occur-rence of depression is not only a functionof strictly medical issues but also to someextent partially created by psychiatric per-sonnel and partially the outcome of socio-processual and not disease matters. Thus,such issues as where or how far a patientresides from a treatment agency, his ac-cess to transportational means, his degreeof distrust or need for self-definition andthe extent to which treatment networksare proliferated and interconnected in anarea will determine how long a patientstays in treatment, ie, the "duration" ofhis depression. Two conclusions can beentertained. First, one needs to adopt acritical posture when evaluating literaturethat centers on how long episodes of de-pression last. Secondly, in our own clin-ical work and in our researches we needto be candid and try hard to ascertain cri-teria that will separate disease manifesta-tions from social behaviors that form apart of the patient's expected role; behav-iors that we ourselves may have a handin perpetuating and possibly to some ex-tent also in generating.

SUMMARYIn this paper, some theoretical and me-thodological problems associated with thestudy of depression in relation to socialsystems were discussed. The first sectioninitially concentrated on how the term"depression" might be handled as a pure-ly abstract and logical entity in the con-

text of general medicine. Then, ordinaryways in which changes referred to by thisterm could be handled in relation to cul-ture and society were described. In es-sence, this involved concentrating on thesemantics of the term "depression." Somequestions and emphases that are ordinari-ly overlooked in cross-cultural studiescome to light when a linguistic analysisof this sort is undertaken. These issueswere explored in the paper. In particular,two general themes were emphasized. Onthe one hand, the various kinds ofchanges that can be implicated and sig-nified by "depression." These changesneed to be seen as more or less indepen-dent on logical grounds if we are toachieve a clear biocultural understandingof what "depression" is. On the otherhand, emphasis was given to how mem-bers of a particular culture can assignmeaning and interpretation to the behav-ioral regularities that can be signified by"depression," as for example coming toview them as representing a disease thatby definition is problematic, undesirableand in need of understanding, control andelimination. The second section of thepaper dealt with problems devolving fromthe study of "depression" in Western na-tions where the changes signified by theterm are in fact seen as constituting a dis-ease, and w here, presumably, definitionaland logical issues are less problematic.Nevertheless, in such socio-epidemiologicanalyses of a psychiatric disease such asdepression one still encounters certaintheoretical problems that need to be madeexplicit. We believe that some of theseproblems are peculiar to psychiatry, a dis-cipline whose disease indicators haveheretofore partaken of and been rooted insocial behaviors. The logical relation thatexists between the disease depression andsocial behaviors makes it difficult to de-



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PROBLEMS IMPLICIT IN THE CULTURAL AND SOCIAL STUDY OF DEPRESSIONvelop suitable criteria of when the disease the fluid nature of depression, in partic-begins and ends. Other problems such as ular, the fact that the components of thethose involved in evaluating hospital rates disease mean different things to membersor estab lishing community morbidity of various social groups, create special an-measures are generic to the field of epide- alytical difficulties that must be taken intomiology. Even in these cases, however, account in evaluating empirical results.

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