Clinical depression treatments: Your soul has a cold (Kokoro no Kaze)

Clinical depression treatments vary tremendously depending on where you live. This comes from the fact that attitudes to depression can be very different across the globe.

Japan traditionally suffered twice the suicide rate of the USA. However, talking about depression in Japan had always been a very different matter from talking about it in Western countries. In our language, the word for depression is interchangeable with dips in landscape, economy or mood. But in Japanese the word for depression (utsubyo) was used only to describe major depressive disorders and/or mania. Indeed it was seldom heard outside psychiatric circles.

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In Japan, to talk about or express feelings, people relied on the word ki or ”vital energy.” When describing low mood people might use the word ‘Ki’ and couple it with expressions of sadness because their Ki was sluggish, blocked or leaking.

Moreover there had always been a keep it to yourself (KITY) social norm in Japan where there was merit in not burdening others with your problems. And for both cultural and religious reasons people with mental health problems like depression were likely to suffer stigmatization, in addition, to the burden of their psychological problem.

Traditionally the major pharmaceutical companies had bypassed Japan when marketing anti depressants because there was not a disorder of depression recognized in Japan to treat and therefore no market for antidepressants. Until that is a new phrase was coined that linked the traditional Japanese notion of Ki and low mood. Kokoro no kaze (your soul has a cold)

Clinical depression treatments: Your soul has a cold

The effect of this clever combination of traditional word and understanding coupled with the new way to talking about something that was an unspoken problem for Japanese society started slowly but with gathering pace to change the status of depression. Depression became defined as a ‘real’ problem. And real problems have real solutions!

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Clinical depression treatments: Antidepressant meds

So far so good. The problem I have with this story is not that depression in Japan was under reported and under treated, I think that is self evident.  And clearly the changing force needed to bring this problem into awareness against a strong and established cultural norm was very substantial. All of that I believe was to the common good. No, the problem I have with this overall approach is that in Japan depression has been characterized as an entirely biological problem that is therefore can only be solved by the use of antidepressant drugs.

Clinical depression treatments:  How the Japanese viewed low mood

To put the problem into an historical context the traditional way of thinking about suffering in Japan may shed some light on why depression was never considered a disease. ‘Melancholia, sensitivity, fragility were not considered to be negative experiences for Japanese hence they were not considered to be problems in need to a solution. They were not considered bad in and of themselves.

Clinical depression treatments: The medical model of depression

In contrast the medical model of depression categorizes suffering as pathological and a problem that requires an intervention. Normally this is a pill. It is the case that the treatment of diseases in more easily understood and funded by health insurance companies and national health agencies and of course the classification of something as a disease helps remove some of the potential for stigmatization. But it also creates a market for the solution where previously none existed. Some critics of this approach have argued that it leads to the pathologisation of normal emotion; the tipping point where moods become medical problems and as such it turns normal human experiences into commodities to be managed.

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Clinical depression treatments: A Little history

Eli Lilly had decided in the late 1980s against selling Prozac into Japan as there was virtually no demand for antidepressant meds. Even though throughout the western world Prozac and other selective serotonin reuptake inhibitors, or SSRI’s were becoming a virtual cultural phenomena – the antidepressant era!

In 1999, Meiji Seika Kaisha a Japanese company began selling the SSR Depromel. Meiji was among the first users of the phrase kokoro no kaze.

The following year, GlaxoSmithKline (GSK) the maker of the antidepressant Paxil joined Meiji by entering the Japanese market.  At this point people did not realize they were suffering from a disease and so GSK put substantial effort into the re-education of the normal Japanese doctor. GSK created a simply message: ”Depression is a disease that anyone can get. It can be cured by medicine. Early detection is important.”

In the early 2000s GSK sent 1,350 Paxil-promoting representatives to visit doctors on average of twice a week. With additional campaigns to teach GPs and their patients about the symptoms of depression: ”head feels heavy, cannot sleep, stiff shoulders, backache, tired and lazy, no appetite, not intrigued, feel depressed.”

Clinical depression treatments: Recognition of depression is useful

I have to acknowledge that recognition of depression is better than not recognising it. Depression is a problem that causes untold misery. Even today in Japan data suggest that 6.6% of Japanese have depression.

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Clinical depression treatments: Depression is a psychological problem

To promote depression as a solely biological problem is to tell an incomplete story. As a psychologist I am not a dispassionate observer of the capture of  depression by the medical establishment. I treat depression every working day and most of the time my clients never use antidepressant meds. Therefore my experience of clinical depression treatments shows me that depression is more than adequately treated by psychological therapy and probably best by CBT Therapy.  Nevertheless most psychological therapies are likely to have value as depression treatments.

I cannot blame the pharmaceutical companies for doing what they do which is to sell pharmaceuticals. And I know it is a common meme to bash the multi national drug companies. I can see they do a lot of good in many areas. If you have malaria you should take an anti malarial medication. But if you have a psychological problem that is better treated by a psychological therapy than a drug treatment then I have an issue with the bias in the message. That’s all.

The moral question is this: are we only consumers or human beings who can also consume? To assert and promote that depression is only a biological problem without also stating that it is a psychological problem is obviously good business for pharmaceutical companies but it is ultimately misleading and I think in the end immoral. If there are better depression treatments even though they cannot be packaged and sold by pharmaceutical companies they have an obligation to inform the public because that is a morally good act. I don’t observe this happening right now. How have we sleep walked to this place in the world where the pursuit of commercial advantage and money takes precedence over honesty, integrity and the common good?

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