Morris Carstairs, a psychiatrist, anthropologist and an academician visited India in 1958 to have a better understanding of the India. He ended up staying in the country for a year but this wasn’t the first time he was here. He was actually born in India in 1916 in Mussoorie, India.
In his time here, he made many interesting observations about the Indian society but probably the most interesting one of them was that in all the time he spent here, he just met one person who had depression. He lived in a rural village of Kerala and so it wasn’t that he rarely interacted with many people. Then why was it that he only met one person who had depression? Was it that Indians were immune to the illness? Or was it something else?
Depression In India in the 60s & 70s
The 60s and 70s were very interesting times for the profession of psychiatry and the field of psychology. As I shared in my previous post, people were raising their voice against the lack of reliability of psychiatric diagnoses. Psychiatry needed to reinvent itself.
At the same time, in India, researchers were trying to look into the presence of mental illnesses in the Indian population. The studies constantly reported that India had a depression prevalence of less than 1%! These studies also found that depression was more prevalent in urban areas compared to rural areas. The scholars at the time attributed this to rapidly changing social surroundings and stress of living in a city.
“Modern civilization, technological complexity and rapidly changing social values seem to be some of the factors contributing to the depressive psychopathology”Sethi, B. B., Nathawat, S. S., & Gupta, S. C. (1973)
But was this an accurate depiction of what the reality was at the time? Today, India has a depression prevalence of between 8-15% at any given time. So, what happened? Did we just collectively become more miserable than we were? Nieuwsma and colleagues (2011) say that this may have been because of the different cultural depiction of depression in India.
The reality was actually closer to home in the USA.
Depression and the DSM
The DSM, which stands for Diagnostic and Statistical Manual is a tool that psychiatrists across the globe use to diagnose people with mental illnesses. The DSM lists out very clear criteria that must be met before diagnosing someone with a disease.
Unfortunately, that wasn’t always the case.
In the late 60s and early 70s, the DSM was just in its second iteration, DSM-II. This tool was quite different from the tool that we are so used to using now. DSM-II relied on the Freudian school of thought and focused on the unconscious and subconscious as a basis for diagnosis. Now you can see how that may be a problem. The DSM-II had the following definition of what ‘depressive neurosis’ (old name for Depression) was,
“This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession”
Read those lines again and compare it to the modern criteria and objectivity in the diagnosis of depression.
The definition relied on people having an emotional reaction of ‘depression’ even though the manifestation of depression is very different in people. They said it must only be due to an internal conflict or an external event but internal conflicts aren’t always known. And depression can occur due to other factors as well.
Its quite clear that the previous definition of depression, as it was in the 60s and 70s was not a reliable or comprehensive understanding of what depression, as we know it now, is. How then do we expect people in India to be diagnosed with depression if the academic understanding of depression was so….abstract?
[Fun fact: Another illness that was a part of the DSM-II, Homosexuality! But that is another story]
Modern Understanding of Depression
Psychologists and psychiatrists around the globe thankfully understood the need to move away from the Freudian ideas of mental illness and moves towards biological and objective methods of assessing the mentally ill. 1980 saw the introduction of the DSM-III which had clear objective criteria to be met before a diagnosis. Once the new DSM was used, depression rates in India jumped up!
Now at the same time, it is important to understand how the previous studies which were based on many faulty assumptions and an abstract understanding of depression may have contributed to how depression is seen in 2020.
The studies at the time have contributed a lot to the stigmatizing attitudes that exist in India today. The higher prevalence of depression in urban areas made people think that depression is an illness of the rich. The definition of depression which focused on the ‘reaction to external event’ made people think that depressed people couldn’t cope with stress of life. Depression thus became a sign of weakness. The increased rates of depression in recent decades were attributed to ‘westernization’ of the society because depression doesn’t exist in India.
The only reason people believe all these things today, and so much more, is because the psychiatrists and psychologists of the time told them that.
It is unrealistic to think that depression didn’t exist in India in the 60s and 70s but we also have to understand that a lack of scientific rigour and objectivity in the psychiatry of the time meant that very few cases of depression were recorded. So, did depression exist in India then?
It did and it did not. Lets just say that its complicated.