This is an ambitious book that explores ‘how experiences of depression differ from other “healthy” forms of experience’. It takes a ‘phenomenological stance’, emphasising attention to aspects of experience that are usually overlooked or presupposed, with a commitment to reflect on them and develop some understanding of their nature. The approach encompasses more than just the experience of abnormality of mood, but takes in how depression influences the experience of the body, the relationship to loss of hope, and the experience of guilt, free will and time.
There is much here that is of interest to psychiatrists. For example, Ratcliffe argues that the current classification systems, particularly DSM-5, do not distinguish between ‘a range of subtly different kinds of experience’. He makes a case for a detailed understanding of subjective experience of depression as this might influence classification, diagnosis and treatment. This position correctly focuses attention on how impoverished the current approaches are, as there is little interest in or curiosity about the nature and narrative of psychopathological experiences, to the degree that ticking off symptoms in a list is deemed sufficient and appropriate for reaching clinical diagnosis.
In the chapter ‘Depression and the Body’, Ratcliffe reminds us that how the body is experienced is intimately affected by depressed mood. Most psychiatrists do not make enquiries about this area unless the patient spontaneously proffers comments that are suggestive of marked alteration in bodily experience. Ratcliffe makes a distinction between ‘noematic feelings’ (in which the body is itself experienced as an object) and ‘noetic feelings’ (in which the body is the means by which the world is experienced). The important point is that, in illness, the body itself becomes an object for us.
These matters are key to our understanding of the nature of depression as it affects bodily experience. Nonetheless, Ratcliffe conflates a number of issues that superficially appear to be related, merely because they seem to inhabit the bodily domain. For example, somatic complaints sometimes refer to disparate bodily sensations that present predominantly in Asian and African patients; in my view, these complaints are quite distinct from negative evaluations of the body and/or self that commonly accompany depression, such as feelings of physical ugliness. Furthermore, there are other bizarre bodily experiences that presage the so-called ‘Cotard's syndrome’. The degree to which some of the bodily experiences, in this context, are metaphors for distress cannot be understated.
Even though this is an admirable book in many respects, there are a number of fundamental problems with it. Ratcliffe developed a depression questionnaire that was administered to an opportunity sample drawn from the website of SANE, the UK mental health charity. The questionnaire was generated from ‘themes that feature prominently in depression memoirs’. How exactly this was done and whether the questionnaire has any validity is not discussed. This approach is curious, particularly as phenomenology has considerably influenced qualitative research and there are well-described methods for conducting interviews that draw on a phenomenological approach. The use of quotations derived from completed questionnaires is difficult to justify. Also, for a book on the subjective experience of depression, it is surprising that anhedonia is not mentioned once and is not listed in the index. This is not a random point; the varieties of anhedonia speak to some of the basic ways that emotions are affected in depression. There is either a total absence of any feeling whatsoever or there is a failure in experiencing pleasure. Although it is true that many narrative accounts make the point that the experience of depression is indescribable, there are aspects that can be described. For example, the time signature of the disturbed mood is well established as a persistently low mood that is invariably worse in the morning and that does not appear to be related to external cues, in comparison to sadness, where the mood is worse as the day progresses and the intensity can be influenced by social context. These seemingly simple or mundane descriptions are part of how depression is experienced.
This is a book for the specialist. It ought to be in all libraries but it is unlikely to directly influence clinical practice.
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