Data Collection

My method of data collection for this thesis combines a review of academic literature on depression, examination of a variety of books and websites on depression, and perusal of material from other sources pertinent to my topic. My primary method of academic data collection for this thesis, which is also my literature review, was via the eJournals and Databases resources available through the University of Tasmania Library. The majority of the data collection and analysis for this study, while not entirely sequential, consists of five main areas: the medical literature on depression; the sociological literature on health and illness generally; the sociological literature on depression and on mental health and illness; literature about depression produced for the public (focussing on the website beyondblue); and literature from a variety of sources, largely literary / historical, concerning the Western approach to suffering. Together, these five areas constitute the sources of the bulk of data used in this thesis and are explored in Chapter Three and Chapters Five to Nine.

Firstly, I examined the world’s leading medical journals (determined by Impact Factor from the Web of Science Journal Citation Reports). I selected The New

England Journal of Medicine, JAMA (the Journal of the American Medical Association), the Lancet, and The Archives of General Psychiatry. I also included

BMJ (British Medical Journal – International Edition) as a balance to United States dominance. To provide an Australian component, I also included the MJA (The

Medical Journal of Australia) and The Australian and New Zealand Journal of Psychiatry. In addition, to be sure of adequately covering the psychological approach to depression (even though this is well covered in the medical literature) I also selected the three most influential psychology journals (also by Impact Factor):

Annual Review of Psychology, Psychological Bulletin, and Psychological Review as well as the Australian Psychologist.

I searched these journals using the terms depression and mental depression, excluding articles dealing with depression and other illnesses (such as cancer or diabetes) or specialized areas (such as post-natal depression or manic-depression). Overall, I limited my search to articles published from 2000 to 2005/6, and later updated my research to the end of 2008. My aim was to gain an overview of the current medical position regarding depression, and from this to ascertain the main themes about depression. This search provided a representative picture of the medical approaches to depression and their points of agreement and contestation. In total, I selected 255 articles (The New England Journal of Medicine: 30; JAMA: 22;

Lancet: 17; BMJ: 72; MJA: 47; The Archives of General Psychiatry: 15; The Australian and New Zealand Journal of Psychiatry: 35; Annual Review of Psychology: 4; Psychological Bulletin: 4; Psychological Review: 2; Australian Psychologist: 7).

The articles I examined consisted of a variety of published material, such as trial reports, clinical reviews, articles, supplements, editorials, commentaries, personal views, letters, and book reviews. I initially organized material and wrote up my findings at length under the headings of diagnosis, causes, treatment, efficacy, education and public awareness, and future research, as these seemed to be the primary categories used in the medical literature when discussing depression. These headings also reflected the focus and areas of interest discernable in the literature. I then applied my theoretical model to these findings, with continual reference back to the literature itself.

Secondly, I examined the Sociology of Health and Illness and Social Science and Medicine to determine sociological approaches to health and illness generally. I was specifically interested in what sociologists had to say about the dominance of the medical paradigm in relation to health and illness. I undertook this search using the terms of medicalization, medicine, and evidence-based medicine (EBM) as my starting points, adding further terms, such as professionalization, surveillance, risk, and power, as these emerged as useful search terms from my initial searches. I sought an overview of what sociologists were thinking and researching. When I began duplicating my finds I decided that sufficient trawling of the literature had been achieved. I limited the search to articles published from 2000 to 2005/6, except where an older article (from the late 1990’s) seemed particular pertinent to my overview.

In all, I selected 75 articles. I read and re-read each of the articles a number of times. In writing my detailed overview of this literature I organised the main emergent themes of individualism, medicalization, professionalization, EBM, power, text, public shaping of science, surveillance and risk, illness narratives, chronic illness and pain, disability, and genetics under the broad headings of scientism, consumerism, and individualism. These themes and headings result from my own interpretation of the main concerns and thrusts of argument and research. Although only some of this material (51 articles) is referred to in my final thesis, all of it provided, nevertheless, a broad and useful background to my research.

The third step in my method was to re-examine these same journals (Sociology of Health and Illness and Social Science and Medicine) for any articles published since 2000 about depression and mental health and illness, which was later updated to 2008. As with the health professional literature review, I was not interested in depression associated with other illnesses or of a specialized type. I searched using the terms, depression and mental depression, and mental illness and health. In all, I read 54 articles (17 on mental health and 37 on depression).

I examined these articles a number of times and found the same sorts of themes emerging that I had found in my examination of the sociology literature about health and illness generally. I initially organised my research under the same themes for

ease of comparison. In the lengthy writing up of my research, I also subsequently grouped these thematic sections under the broader headings of scientism, consumerism, and individualism. I then applied my theoretical model to these findings, while also constantly referring back to the literature itself. To check I had not missed any important literature from these journals I also searched via the Sociological Abstracts database and found the same articles being duplicated. In addition, I also read a number of general sociology texts on health and illness, mental health and illness, and depression. These provided further background information about the main concerns, issues, approaches, and research areas in the field of sociology.

In my fourth step, I examined four of Australia’s leading depression websites (Griffiths and Christensen 2002): beyondblue, Black Dog Institute, BluePages and

CRUFAD (Clinical Research Unit for Anxiety and Depression). I also studied a number of books produced for the general public about depression. Most of this material, particularly the websites, was examined later in my doctoral candidature for its content as it related to what I had found in the medical and sociological literature. I was interested to discover in what ways the content of this material reflected content in literature from the academic domain and in what ways it differed. In my final writing up, I focussed on beyondblue, as I found it representative of material about depression produced for members of the general public.

Finally, in a process that spanned most of my doctoral candidature, I explored literary / historical sources for approaches to suffering. From the vast plethora of material available, I made selections based on their ability to clearly demonstrate, whether overtly or indirectly, an engagement with questions about suffering and the human condition. There are numerous texts that would have admirably served such criteria and from these I chose two representatives from Western antiquity, an ancient Hebraic text and ancient Greek ideas concerning tragedy, and two selections from the contemporary West, secular-atheistic literature and Christian hymns and songs. I avoided producing either a history of medical or literary approaches to sadness as these are already well researched (e.g., Horwitz & Wakefield 2005, 2007, Kleinman 2007, Wilson 2008). I read this material very closely to identify any commonality of themes about suffering and discovered an extraordinary perpetuity in

the identified themes. From these identified themes, I constructed a set of ‘motifs of suffering’ against which I situate my study of the Western framing of depression.

In the course of my research, I was sometimes alerted to the existence of other material that seemed pertinent to my topic. Where possible I obtained these articles or books for examination or perusal, depending on whether I found them directly or only tangentially related to my area of study. Nevertheless, such serendipitous encounters were sometimes an invaluable source of material; indeed, it was through such a meandering route that I discovered the potential value of utilising Weberian ideas for the theoretical foundation of my study.

In the process of writing the final drafts of the chapters (see Chapters Five to Nine) in which I applied my theoretical model (see Chapter Four) to the data I had examined I decided to focus on the medical material on depression, referring to the sociological material where applicable to, or useful for, my discussions. My reason for adopting this approach was that the medical paradigm of depression, despite internal disagreement and contestation, is not only dominant in the contemporary West it actually constitutes, in a very real sense, the contemporary Western framing of depression. External parties, such as governments, policy committees, pharmaceutical companies, and health care insurers, do unquestionably influence medicine. However, it is medicine, in a complicated weave of interrelationships with these external parties, which provides the foundation from which they in turn exert their influence over medicine and society as a whole. My study therefore, necessarily concentrates on the medical position because it drives and determines, far more than the sociological position, the contemporary framing of depression in the West in all its woven complexity. To take any other approach, such as evaluating the sociological and medical literature equally, would be to blatantly ignore the reality of medicine’s hegemonic position in the contemporary West.

1.4.2 Process

The process utilized in this study was a multi-track journey into theory selection (see 2.2), development of methodology (see 1.3), and data collection. Although I began

my research with an interest in the virtual absence of spirituality in approaches to depression, and had planned to use Derridean textual deconstruction, I also explored a number of other possibilities. As with choosing a theoretical framework, data collection and assessment of possibilities proceeded down a number of interesting routes, even though most eventually proved to be dead-ends for my purposes.

For example, I examined the possibility of comparing psychiatric approaches to depression from the early 1800’s with today by using archival material housed in the Tasmanian State Archives and in the University of Tasmania’s Morris Miller and Clinical libraries. For a time I considered the idea, following Szasz (1970), of approaching the contemporary Western framing of depression through an examination of the correlation between medicine and the Inquisition in their denoting of ‘other’ as abnormal or evil, respectively. I also explored the idea of an historical examination of allopathic and homœopathic approaches to depression compared with contemporary approaches. Another possible direction was to examine past psychiatry textbooks compared with contemporary psychiatry textbooks, but discovered that, unfortunately, when the Royal Derwent Hospital9

was closed all the old books were discarded. However, after a number of ‘trawling expeditions’ to identify if data collection was viable I decided against these potential directions as a way of exploring my topic of depression. In addition, I also looked at approaching my topic in the area of the sociology of chronic illness or disability, looking specifically at narrative and meaning. I was particularly interested, inspired by, for example, Kleinman (1988), Karp (1996), Frank (1997, 2000), Ezzy (2000), Bury (2001), and Dowrick (2004), in the value and possibilities of using narrative as a method of data analysis and as a way of approaching the subject of depression.

The whole research process was exciting, if at times tedious and frustrating, as I pursued paths not originally intended or even imagined. It was also sometimes frightening and unsettling as I allowed the material to take me in unplanned directions, rather than attempting to fit material into predetermined boxes. In hindsight, I can see that there was a particularly synergistic relationship in my

9 _{Under various names, the Royal Derwent was a hospital / asylum for the “in-patient treatment and}

research between methodology, method, and theory as I moved backwards and forwards between data, rationale, process, method, theory, and purpose before finally establishing my own theoretical model from which to examine the data through a hermeneutic methodology. Without this convoluted and organic process in my method, as well as in my methodological and theoretical approaches, it is unlikely I would have produced this study as it now stands.