Authors' reply

Mushtaq shares my concern about inappropriate medicalisation, but sees short-term interventions such as CBT as something apart. I must disagree: talk therapies delivered in the National Health Service by mental health professionals are part and parcel of what profession and public understands by ‘medical’.

In working to produce ‘culturally sensitive CBT’ for depression in Pakistan, Rathod et al hope that mere adaptation of standard practices and manuals, and good translations, will do the trick. I'm afraid I challenge the assumption that Western psychiatric templates can generate a universally valid knowledge base. ¹ Methodologies routinely fail the core test of scientific validity, which relates to the ‘nature of reality’ for the individuals under study.

Globalising Western psychiatric approaches is not value free. A telling example of the moral and political shifts to which I alluded in the debate is provided by the invasion of Latvia by the diagnosis of depression. ² This was prompted by the translation of ICD into Latvian, and by conferences organised by pharmaceutical companies to educate psychiatrists and general practitioners (who in turn educated their patients) about this new diagnostic category. This was a radical departure from the traditional language of (largely somatic) distress – notably nervi – shared by doctors and lay public. To present nervi was to invite a life story, which could include a critical commentary on disorder or dysfunction outside the self, in wider society and politics. The doctor-mediated shift from nervi to depression is a shift away from the lived contexts that nervi embodied, the focus now inwards to the individual person. With this comes the internalisation of a heightened sense of personal accountability for life circumstances. However, at the same time post-Soviet Latvian society has lost much of its former sense of stability and security, and most people have in fact less control over their lives. The narrative structure of these new accounts of distress indicates that Latvians have internalised the values of capitalist enterprise culture and the responsibility for personal failure that goes with it. It is this shaping of a different kind of citizen that is evoked in the globalisation of depression.