The cultures of depression.

Diverse frameworks, models and 'cultures' of depression have been postulated and promoted by psychiatrists, the pharmaceutical industry, general practitioners, primary care psychiatrists and the general population. Psychiatrists and the pharmaceutical industry endorse the medical model while general practitioners and the public subscribe to social and psychological frameworks. These models are partial truths and should be viewed as complementary rather than competitive, some more valid in a specific context than others. The issues that need to be resolved include: (i) reexamination of the validity of the psychiatric diagnosis of depression in the primary care context; (ii) a review of the adequacy of a single label of depression to describe the diverse human context of distress; (iii) acknowledging the problems of using a symptom checklist in diagnosing depression; (iv) recognizing the need for psychosocial diagnostic formulations which clearly state the context, personality factors, acute and chronic stress and coping; (iv) highlighting the fact that antidepressant medication should be reserved for severe forms of distress; (v) re-emphasizing the need to manage stress and alter coping strategies in the treatment of people with such presentations; (vi) de-emphasizing medicalization of all forms of personal and social distress; (vii) focusing on other underlying causes of human misery including poverty, unmet needs and lack of rights. Clinically, there is a need to look beyond symptoms and explore personality, life events, situational difficulties and coping strategies in order to comprehensively evaluate the role of vulnerability, personality factors and stress in the causation of depression.