The prototypes for medical diseases are (apparently) clear-cut pathologies like diabetes or cancer. According to Ian Hacking, in the current medical climate “the names for real
illnesses have objective, individuated referents; scientific metaphysics and popular science alike demand that the referent is biochemical, neurological, organic, something that could in
3It might seem more natural to use the term ‘sadness’ here, rather than the cumbersome ‘normal low mood’
locution. Sadness, however, is commonly used for both emotion and mood states. I wish to remain clear that my concern is with mood.
principle be isolated in the laboratory.”4 What Hacking is describing in this quote is what is commonly referred to as the ‘medical model.’ The ‘medical model’ is the set of beliefs held by medical practitioners and educators about what a disease is, what the roles of various medical practitioners are, what the goals of treatment should be, and what counts as a cure. Because the practice of medicine in this culture is so large, there is considerable
heterogeneity within the medical model. In this section, I will discuss one such model, Medical Model A. The influence of Medical Model A is substantial among the clinicians and researchers who analyse psychopathologies.
Within Medical Model A, clinicians and researchers understand diseases exclusively as physiological pathologies. For example, according to a recent volume on disease and its origins used by a variety of medical schools, “the cause of disease comprises either a [physical] event that overwhelms homeostatic mechanisms (an extrinsic cause) or one that undermines them (an intrinsic cause).”5 These pathological events will typically manifest themselves in physiological symptoms. Different causes will result in different symptoms and the aim of diagnosis is to provide a taxonomy that aligns symptoms and causes through explication of a common physical causal mechanism. Treatment should ideally be directed at that underlying intrinsic or extrinsic pathology. On this model, mental diseases are
physiologically grounded brain malfunctions that result in unpleasant psychological states. Establishing this physiological underpinning also establishes the non-volitional quality of the disease in question. This is important in a variety of respects, notably because, as I mentioned earlier, there is a link within our folk medicine between disease and lack of
4Hacking 1998, 10. 5Scriver et al. 2001-2005.
responsibility.6 On the dominant cultural view, having a medical disease confers certain privileges on the sufferer. To have a medical disease is to abdicate certain responsibilities — it is not your fault that you are unwell, and because you are unwell, you do not face the same obligations that you would otherwise have to meet. This privilege ought only to be bestowed upon those who really cannot help their condition. If a mental disease has an underpinning in physiological malfunction, then surely its symptoms are not under conscious (or
unconscious) control and medical doctors are the right kind of experts to respond to it. Sometimes, questioning the legitimacy of characterising a particular psychological
phenomenon as a mental disease is intended to ensure that the phenomenon is not the product of (sub)conscious efforts by patient, physician or community at large. This is, for example, largely the motivation behind raising critical questions about the diagnosis of multiple personality disorder. There is a desire to be certain that neither sufferer nor doctor nor mass hysteria is ‘making it up.’ There is also a need to ensure that the unpleasant psychological state in question is not simply a normal part of being a person. This is the motivation behind questioning diseases like attention deficit disorder. Calling very active and inattentive children (typically boys) ‘sick’ worries many, since we think it is part of normal human variation for at least some children, notably boys, to be very active and inattentive. In additional to non-volitionality, typically diseases are considered to be pathologies that are beyond the scope of normal, or reasonable, human experience.
6There are, of course, exceptions to this view. Smokers with lung cancer are clearly considered to have a
disease but they may still be held responsible for it. I do not believe, however, that persons who are seen to have clear cases of mental disorders are in this category. To the extent that some non-clinicians do hold persons with, say, schizophrenia, responsible for their symptomatic behaviour, I think it is because they are not seeing the phenomena exclusively as a disease.
Both low mood and current cases of diagnosed depression certainly qualify as unpleasant psychological states, but many instances seem to be states that are normal, an ordinary part of human experience. Everyone experiences a low mood sometimes, and moreover, as I
mentioned in the introduction of this chapter, the prevalence of diagnosable depressive disorders in North America is staggering. I think the sheer normalcy of low mood / depressed experiences should prompt skepticism about whether or not many of these are genuinely pathological phenomena.
This idea that mental diseases are only real if they are malfunctions grounded in
physiology or materially caused rests on the commitments currently held by Medical Model A. Further, Medical Model A demands that practitioners ought to aim to eliminate mental disorders by fixing those deviant physiological causes, and the elimination of physiological dysfunction is best accomplished through material, namely, pharmaceutical, intervention. As the cause of the disease is material, so too must be its cure. A common unwarranted
corollary to this position is the idea that if there is a material treatment for an unpleasant psychological state, then there can be confidence that this psychological state is a mental disease. Treatment in this instance just means that the unpleasantness of the psychological state is eliminated.
It is my contention that these (implicit) beliefs are evident in the expansion of depressive diagnoses. Further, I believe that this expansion has been fueled by the advent of new anti- depressant pharmaceutical interventions. In order to establish this claim, I must first show that depressive diagnoses have in fact been expanding, and then show that there is reason to believe that availability of new drug therapies has motivated it.