Archives of Psychiatric Nursing
Volume 23, Issue 3 , Pages 183-184, June 2009

“Normative orthodoxies in depression and the ‘space’ for alternative discourses”

David G. Braithwaite Professor of Nursing, The University of Texas at Tyler

Associate Dean: Psychiatric Nursing, Stenberg College, Vancouver, Canada, Adjunct Professor of Nursing: University of Ulster, UK

Associate Editor (Americas): International Journal of Mental Health Nursing

Assistant Editor: International Journal of Nursing Studies

Article Outline

 

Irrespective of the country where one practices or the particular population(s) that one works with, the likelihood is extremely high that as a psychiatric nurse, you will encounter depressed people. Though the well documented problems in determining a case/non-case of depression mean that the associated epidemiological data should be treated with an appropriate degree of caution (see Tanney, 2000, Van Praag, 2004, Van Praag, 2005) the World Health Organization (2009) indicate that the global rate of depression continues to rise. At the same time, there exists a parallel and more compelling body of evidence that shows how the incidence of prescriptions for anti-depressants (most noticeably Selective Serotonin Reuptake Inhibitors – SSRIs) has risen dramatically during the last two decades, particularly in ‘western’ countries (see Barrkman, 2009, Hemels et al., 2002, MIND, 2009). With these data in mind, and with reference to mental health policy literature, national treatment guidelines and the not insignificant marketing campaigns of giant pharmaceutical corporations, the inescapable conclusion is that the contemporary orthodoxy for treating or ‘fixing’ depression is firmly embedded in a biological disease model and the corresponding (automatic) pharmacological response.

Interestingly, when one considers the state of the science this can be regarded as a somewhat counter-intuitive situation. While the almost hyperbolic assertions that depression is a biological disease like any other biological disease (e.g. diabetes) continue, a more candid appraisal of the current state of the science indicates that it is disingenuous to make such claims. The scientific academe currently has not isolated or identified the necessary biological markers that are required for external validation of depression as a biological phenomenon (see for example Stevens, 2009). Indeed, no blood test, pathognomonic test or specific anatomical lesion can be found for any major psychiatric disorder (see also Breggin, 2000).

Now, this state of uncertainty and the accompanying epistemological scientific state of mind (referred to as ‘open-minded realism’ see Harding and Hare, 2000, Harwood et al., 2005) means that we must accept the possibility that future discoveries could show that depression is a biological phenomenon. Equally, this uncertainty also means that there is ‘space’, if not a requirement for, alternative discourses as to the nature of and appropriate response(s) to depression.

One such alternative discourse posits for some, an axiomatic truth: namely changes in mood and with that, periods/experiences of depression, are a part of the human condition ergo to be human is to experience depression at some point during one's existence. Interestingly, this discourse does not suggest that people experiencing depression should simply be abandoned as their experience is simply ‘part of being human’; what is does highlight however is that depression (for many) can be regarded as part of the human experience and thus not necessarily something that has to be ‘cured’ or fixed (Szasz, 1961, Szasz, 2007). Additionally, that it can be considered an experience that people need assistance to live with or through. Further, that this parallel discourse emphasizes a range of non-pharmacological interventions for alleviating depression, each of which has an evidence-base, including: exercise regimens, cognitive behavioral therapy, exposure to light therapy, and other talking therapies including exploring the meaning of experiencing depression. Moreover, the discourse acknowledges that in the search for a world where the automatic response to depression is a pharmacological intervention, we may simultaneously be inhibiting the person's chance to explore the meaning of their experience and preventing people from individual growth/personal development.

Interestingly, examination of contemporary psychiatric nursing literature from around the world shows that some of the most ardent and vocal ‘supporters’ of (automatic) pharmacological responses to people with mental health problems are psychiatric nurses (see for example Jones and Gray, 2008a, Jones and Gray, 2008b); which is a conceptually problematic situation given nursing's exhortations that we base our practice on a holistic (not reductionist) philosophical view of people. Accordingly, while it may be inappropriate to abandon the practices subsumed within the current dominant discourse, it is similarly inappropriate to not explore and/or reject the alternative discourse(s) regarding depression. This is a hitherto unresolved debate and one that psychiatric nursing needs to enter into with gusto. Some of these key ideas and their associated evidence bases will be explored in a forthcoming paper (Cutcliffe and Lakeman, in press) and I sincerely hope that others will join in and contribute to this debate; our own ‘open-minded realism’ requires each of us to be receptive to a range of possibilities rather then reaching and practicing from the basis of premature epistemological conclusions regarding depression.

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References 

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PII: S0883-9417(09)00044-2

doi:10.1016/j.apnu.2009.03.004

Archives of Psychiatric Nursing
Volume 23, Issue 3 , Pages 183-184, June 2009

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