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Article Highlight: Feeding Tubes and Quality of Life in ALS Patients

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This week on the blog, we are highlighting Jeannette Pols and Sarah Limburg’s article “A Matter of Taste? Quality of Life in Day-to-Day Living with ALS and a Feeding Tube.” The article is open-access and can be read in full here on our publisher’s website.

The authors begin by suggesting that while “quality of life” has been transformed into a measurement used widely in health research, it is difficult to operationalize when considering the daily, lived experiences of patients. Rather than approaching quality of life as a measure of attainment or “outcome,” the authors instead choose to reframe it as a continual process: one that is negotiated by individual patients differently. To examine what quality of life entails in a qualitative sense, the authors interviewed a population of people with ALS in the Netherlands with feeding tubes, or ALS patients considering one.

The literature on feeding tubes, the authors note, present many perspectives on the relationships between quality of life and eating. Some sources argue that feeding tubes deprive individuals of the important social aspects of eating, while others note that feeding tubes can unburden patients for whom swallowing and the physical actions of eating are difficult, uncomfortable, or impossible.

Patients and their families interviewed by the researchers, on the other hand, demonstrate such ambiguity towards feeding tubes contextually, depending on the stage of their feeding tube transition. For many, the initial decision to have a feeding tube placed in their bodies was an upsetting signal of bodily deterioration. The procedure itself, though technically minimally invasive, was also viewed with trepidation by patients. They worried about the hospital stay, and whether or not their body would be strong enough to adapt to the tube quickly. Pols and Limburg found that for those who had undergone the procedure, “there was a remarkable consensus among patients in their evaluation of tube placement, with the main variations mentioning just how terrible it had been.” The authors later note that some patients continued to view the feeding tube negatively after it was placed, envisioning it as an unnatural, upsetting addition to their bodies. Others described it as a “necessity” that came with quality of life benefits, although it was not pleasant to have attached to their bodies.

However, for many patients who had feeding tubes already implanted at the time of the study, the response could be notably positive. These participants noted that the devices restored their health and function, and lessened distressing symptoms like choking and an inability to swallow. For one patient, the feeding tube ensured that she received the appropriate calories, such that any food she decided to eat normally could be at her discretion. Other patients who cared less about eating a range of foods appreciated that the feeding tube rid them of the need to worry about what could be easily consumed.

The authors conclude that “the feeding tube can best be understood not as an intervention that causes ‘impacts on quality of life’, but as a technology or prosthesis that may bring different qualities and appreciations that may shift over time.” They add that the feeding tube acts as an intervention that re-orders daily life for patients coping with the a ‘new normal’ of chronic illness: rather than serving to balance “good” and “bad” qualities, as outlined in the disability paradox. Lastly, they remind readers that instrumentalizing “quality of life” risks losing these facets of illness experience. This term is deeply contextual, and responsive to the needs, expectations, and hopes of each patient undergoing treatments or coping with chronic conditions.

Issue Highlight Vol 40 Issue 1: Regulating Anger in Urban China

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The March 2016 issue of Culture, Medicine & Psychiatry is here! Over the coming weeks, we will feature article highlights from a selection of the newest research published at our journal. To access the full issue, click here.

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In today’s article highlight, we examine Jie Yang’s research in “The Politics and Regulation of Anger in Urban China” (accessible here.) Yang’s article ethnographically maps the connections between statewide therapeutic programs and the management and expression of anger amongst largely working-class, urban Chinese men and women.

Yang begins by noting that urban social workers and other clinicians place a strong emphasis on the treatment of negative psychosocial symptoms, and frequently relate poor physical health– as well as social unrest– to unmanaged expressions of anger. Their agenda reflects that of the Chinese state, which simultaneously values individuals’ happiness and pathologizes anger. Amongst the working class and the poor in China, however, some social ills which lead to detrimental emotional outbursts are indeed related to the state’s management of social life. Yang cites one example in which a Chinese man masterminded a bus explosion which resulted in numerous fatalities. His outburst was a heated response to the government, which repeatedly failed to approve his pension and dismantled his street stall: his only source of income. Thus anger proves to be a harmful, yet powerful, mechanism for the working class to vocalize frustrations with the government and injustices stemming from the failings of the state.

The author continues by describing a range of anger “genres” employed by the Chinese working class. These “genres” describe performative types of anger expression that have different roles depending on the nature of the injustice one is responding to. One form of expression, maije, is a form of public cursing– often on the street– to widely verbalize one’s frustrations and vulnerability due to poor working conditions. Another form, xiangpi
ren, refers to “a human punching bag,” or someone who does not outwardly respond to an injustice and seems to passively internalize their negative emotions. The advantage to this form, however, is that such individuals may be preparing for a specific opportunity to “rise up” in protest.

In addition to the array of expressions and forms that anger may take, Chinese individuals have an equally pluralistic selection of therapeutic interventions to manage or alleviate their anger. This includes Confucian, Daoist, Western, and folk Chinese remedies for psychological distress. Conversely, therapists who serve the state have social access to this range of modalities and psychological concepts, thus arming them with various mechanisms for managing and controlling “angry” individuals.

After exploring genres of anger in greater detail, both from the individual and clinical perspectives, Yang closes by positing that “the domestication of anger is key to sustaining
stability in the Changping factory and in China at large. It contributes to the relative
peacefulness in China amidst widespread socioeconomic transformation.” As therapists and state-employed clinicians seek to tame anger, so too do they attempt to recast anger as a personal expression of injustice rather than a social symptom of widespread unrest. Anger thus remains a prominent vehicle for the expression of individual as well as social injustice across a shifting socio-economic landscape.

 

 

Issue Highlight Vol 40 Issue 1: Depression, Gender & Power

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The March 2016 issue of Culture, Medicine & Psychiatry has recently debuted. Over the coming weeks, we will feature article highlights from a selection of the newest research published at our journal. To access the full issue, click here.

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This week’s article highlight examines Alex B. Nietzke’s piece “An Illness of Power: Gender and the Social Causes of Depression” (accessible here.) Nietzke argues that a mechanistic and biological model of depression overlooks the extent to which women across the world are frequently diagnosed with the disorder at a higher rate than men. When bioscience and biomedicine fail to attend to underlying social and gendered dimensions of depression as a diagnosis, the author holds, they are “silencing women” and “marginalizing” a discourse surrounding the problematic social power of the biomedical model.

The article opens with a review of the literature on medicalization, which describes the shift from a psychodynamic model (where external factors were typically considered the source of reactive mental distress) to a biopsychiatric one (where, given the development of medications for mental disorders, mental illness was increasing viewed as seated within the patient’s biology.) The DSM-III later “eliminated” the categories for “reactive” mental illness, and placed physical symptoms (like weight loss) alongside psychological ones (like feelings of hopelessness) such that both expressions of illness were physiologically equated to one another.

Upon biologizing symptoms, the causes of depression thus fall wholly within the realm of biomedicine to diagnose and to treat. This leads to a nearly unilateral assumption of control over depression by psychiatrists and clinicians, even if other individuals such as family and friends– and the patient herself– has insights into the social determinants of a psychological condition. Furthermore, when biomedicine interests itself only in the biological and not social basis of women’s mental illness, it delegitimizes the very roots of many women’s distress and reinforces their inability to verbalize forms of oppression. Nietzke thus adds that “what begins to emerge here is that the psychiatric disease model of depression may actually be disempowering women by legitimizing the pathologies of a social system of gender as it delimits one’s expression of suffering and testimony to its causes.”

When biopsychiatry quiets the discussion of social determinants of mental illness, so too does it lend power to the systems of oppression that enable women’s suffering to continue, and limits their ability to express their psychological state. Put another way, by biologizing rather than contextualizing depression, women are inherently marginalized because they may have few other recourses outside of biomedicine for ameliorating the psychological ramifications of social disenfranchisement. The “silencing” Nietzke cues in the early paragraphs of the article returns here, as the author reminds readers that biomedicine’s biologizing of depression may problematically close the conversation around the social situatedness of women’s psychological experience and social status.

Issue Highlight Vol 40 Issue 1: Hope, Despair, and Chronic Pain

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The first 2016 issue of Culture, Medicine & Psychiatry has arrived! Over the coming weeks, we will feature article highlights from a selection of the newest research published at our journal. To access the full issue, click here.

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In this week’s blog, we visit Eaves, Nichter, and Ritenbaugh’s article “Ways of Hoping: Navigating the Paradox of Hope and Despair in Chronic Pain” (accessible here.) The authors carried out a series of qualitative interviews with patients experiencing temporomandibular disorders (TMDs) throughout a clinical trial where these patients received traditional Chinese medical treatments (TCM.) The authors’ research with 44 patients in the clinical trial highlight the paradoxical nature of hope: that is, a tendency to both place faith in the possible efficacy of a treatment, while cautiously gauging these expectations to avoid feelings of despair should treatment fail to produce a positive result. The authors argue that hope serves as a complex placebo, in that while not itself being an active pharmaceutical or other intervention, it can have significant implications for a patients’ course of care.

Following a review of methodology and the theoretical basis of medical “hope,” the authors present a diverse array of examples from their interviews that illustrate the range of expectations, beliefs, and experiences of the chronic pain patients. For some patients, hope is secular: related to realistic treatment goals (such as a small reduction in overall pain), or to utopian ideas about the treatment’s future potential for other patients. For others, hope is an expression of spiritual faith, or a form of almost religious belief in the effectiveness of bioscientific breakthroughs, or even a belief that biomedicine has failed the patient and a remedy for their pain can only be found in other medical systems (like TCM.) Other patients described an embodied response to the treatment that, the authors comment, underscores the relationship between placebo and (psycho)somatic healing.

In all these examples, however, what is perennially apparent is the patients’ tenuous balancing of hope with tempered expectations for a cure. However it comes to be framed, hope both enhances and complicates the treatment of chronic pain. In some cases, hope acts as a “positive” placebo in that it bolsters the patients’ faith or trust in the potential (or even observable) efficacy of the treatment. In other instances, hope can prove to be a harmful placebo in that it may promise beneficial change and render any failing of an experimental treatment more troubling for the patient. Because hope offers such conflicting possibilities for patients’ satisfaction and trust in a treatment modality, it is essential for both anthropologists and clinicians to consider the cultural, cognitive, embodied, and religious frameworks in which a patient conceptualizes and subsequently approaches treatment.

Issue Highlight: Vol 39 Issue 4, Stimulant Use in the University

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This blog post is the last in a three-part series highlighting our newest installment of Culture, Medicine & Psychiatry (released December 2015) which readers can access here. This week, we explore Petersen, Nørgaard, and Traulsen’s research on the use of prescription stimulants amongst university students in New York City. The full article is available here.

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In recent dialogues on the widespread use of prescription stimulants amongst university students, drugs are often described as enhancing productivity or a student’s ability to successfully focus on academic work. However, Petersen, Nørgaard, and Traulsen found that university students in New York City often cited the use of these drugs as rendering their work more pleasurable, “fun,” and “rewarding.” Their study included 20 students spanning BA, MA, and PhD programs: representing a diverse sample that, in the aggregate, universally suggested that the use of stimulants in an educational setting was not centrally connected to academic output or production. This outcome, the researchers assert, complicates existing neoliberal readings of American personhood, premised on the idea that the self is primarily cultivated and disciplined through labor and individual productivity.

For example, rather than feeling shameful about using stimulants to improve study skills or produce better work, the students instead expressed guilt for enjoying their academic labors and for transforming “monotonous” and “boring” activities into an engaging experience. The “optimization” of the mind to perform intensive intellectual labor was not related strictly to productivity, which would evoke traditional neoliberal notions of the person-as-producer. Instead, the students described the drugs as optimizing pleasure first, which rendered them more productive as a secondary consequence.

Take this instance: a 32-year old PhD student, identified as Ben, reported using Adderall when he felt too “lazy” to initiate work. Rather than continuing by discussing the extent of his productivity while on the drug, he instead explains that the drug makes him eager “to tackle” his projects. This is often the case for students who struggle to find the desire to complete academic tasks that are not interesting enough to begin without being made pleasurable through stimulant use. Further, another student added that using stimulants helped him to “reconnect” with his interest in sociology during a difficult class on social science theory. In other cases, using Adderall kept students from being distracted from social media or entertainment websites: not because they lacked the inherent ability to be productive, but because without the drug, these sources of interest were simply more engaging than the work at hand. In other instances, students noted that stimulants made them feel more secure and positive about the quality of their work, and helped them to diminish the physical and mental stresses that came with “all-nighters,” or extended overnight studying stints.

Throughout all these cases, enhancement is not described as a means to make the human brain meet the demands of a “high-speed society.” Instead, “enhancement” relates to students’ satisfaction with their resulting work, to their enjoyment of otherwise “boring” tasks, and to reduced the negative psychosomatic effects of studying or working on a limited time frame.

The authors do not eschew the neoliberal model through these cases: indeed, they suggest that the use of stimulants does have cognitive effects that bolster students’ abilities to produce academic work. However, they note that we must complicate a strictly neoliberal model that would indicate that stimulants are employed by students strictly in order to achieve a certain amount of studying or to complete an assigned amount of work. Enhancement may include productivity, but for students who use stimulant drugs, it also involves increasing the pleasure of finishing intellectual labors, and decreasing the negative consequences of engaging in challenging or otherwise tedious academic work.

In this way, cognitive-enhancing drugs indeed fortify the mind and the conception of the self as a producer and academic laborer. However, they also shape human experience by altering students’ sense of confidence, their satisfaction with academic work, and their passion for their chosen topics of study. In these ways, enhancement drugs not only increase productivity in the neoliberal sense: they also broadly impact notions of pleasure and individual ability related to students’ quest to heighten academic production.

 

 

Issue Highlight: Vol 39 Issue 4, Incarceration & Medical Anthropology

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This blog post is the second installment of our three-part issue highlight on the new December 2015 issue of Culture, Medicine & Psychiatry (the full issue is accessible here.) In this week’s blog, we examine Carolyn Sufrin’s article on the shared roles of clinicians and anthropologists working with incarcerated women in the United States.

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Clinician-anthropologists are in a unique position to lend voice to their participants and to care for their medical needs. For Carolyn Sufrin, who served both as a physician and an ethnographic researcher for incarcerated women in the United States, the clinical and anthropological roles intersected in deeply meaningful ways. Sufrin notes that in these dual roles, she observed with female prisoners and analyzed their experiences, and provided reproductive health care and delivering the same women’s babies in a county hospital, where imprisoned women gave birth. The women were alternately enrolled in Sufrin’s study upon ceasing to officially be her patients, or were individuals that Sufrin cared for during her tenure as their OB/GYN.

Sufrin uses her case as an example of how to interpret the ethical consequences of working as a clinician-anthropologist. Part of the challenge she faced as both a physician and anthropologist to the women was that IRB and HIPAA regulations divided the types of data she could use in her anthropological research. Though some details of her participants’ lives, such as past trauma or childhood abuse, were essential to their experiences as mothers and as incarcerated women, she could not use this data inasmuch as it had been shared with her in the context of a patient-practitioner interaction: in other words, it was considered classified personal health information that could not be subsequently utilized in her ethnographic research. These methodological hurdles, Sufrin explains, shed light on the complexities of what constitutes “sacrosanct” data. It also suggests how the safeguarding of medical data does not necessarily translate to the “protective” collection of ethnographic data which is not isolated to the case of individual patients, and which relies on knowledge of participants and their connections to other people (in this instance, to individuals in the participant’s life who had caused past psychological harm.)

Likewise, as stated earlier, relationships between the participant/patient and the clinician/anthropologist are another form of interpersonal connection which must be reconfigured depending on the nature of the exchange taking place. In Sufrin’s case, this meant being clear with her participants that– upon entry into her anthropological study– she was no longer their physician, and that the nature of their exchanges and their professional relationship would take a new form. She could share their information (albeit de-identified), unlike information drawn solely from their medical records or from an examination.

Yet here, Sufrin notes that the anthropologist– like the clinician– is still engaged in an ethic of care. For example, one of Sufrin’s former patients in the prison was charged with child endangerment after giving birth in an alley and handing her child to a stranger, unable to afford treatment at a hospital following her release from prison. The story made news headlines, and as public knowledge, was within the realm of information that Sufrin employed in her ethnographic analysis of reproductive health in the American prison system. However, Sufrin knew an added piece of information that was not already publicized from her interaction with the woman in prison: a clinical detail that she understood as a physician, but was shared during her time as an ethnographic researcher. This detail would have enhanced her analysis of the situation, but she chose to omit it out of concern that to publicize the detail would be to betray the woman’s trust in her as a researcher and as someone who served in the prison as a physician.

In other instances that Sufrin discusses, her role as both an anthropologist and clinician led the women she worked with in each capacity to feel as if she was especially attentive and caring. Rather than always relying on her medical authority, Sufrin underscores her decision to remain non-judgmental and supportive even when the women in her study had made potentially harmful choices; for example, she chose not to openly admonish a woman who was continuing to use crack upon release from jail, despite being thirty-two weeks pregnant. Sufrin notes that her silence hid her own frustration with this choice, but it strengthened the woman’s trust in her as an anthropologist and “as a doctor.”

In sum, these dual roles ultimately bolstered her relationships to the incarcerated and formerly incarcerated women that she served. Thus, the author argues that both anthropologists and clinicians share an “ethic of care” in their relationships with research subjects or patients. This ethic involves a careful fostering of the professional, interpersonal connections that ethnographers make with research participants, or that physicians make with their patients. This care entails the protection of private information and the researcher/clinician’s conscious attendance to interpersonal exchanges that bolster the patient/participant’s trust in the clinician/anthropologist. Likewise, an analysis of the clinician role alongside the anthropological one demonstrates both the delineations between multiple forms of care and social connection, as well as the shared commitment in medicine and anthropology to the sensitive attendance to patient and participant experiences.

Issue Highlight: Vol 39 Issue 4, Posthumous Reproduction

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Our final issue of the year– Volume 39 Issue 4 December 2015– has just arrived. In our last blog post series for 2015, we begin with a three-part feature of the latest publications at the journal in this new issue. In addition to the article previews in this series, our readers can access the full issue here. In this post, we explore Yael Hashiloni-Dolev’s preliminary research on posthumous reproduction in Israel (full article accessible here.)

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Biomedicine, through its innovative application of technology, can reconfigure biological experiences in ways that alter or reinforce cultural beliefs surrounding life, death, reproduction, kinship, parenthood, and social roles. Most recently, this has become a central issue in the field of assisted reproductive technologies: where biomedical interventions potentiate new relationships between parents, families, and children. But while assisted reproductive medicine is often discussed in terms of generating life, these new generative technologies may also intersect with death in novel ways that challenge existing understandings of kinship and familial relationships.

Hashiloni-Dolev article studies Israeli lay perceptions of a new concept in assisted reproductive medicine called posthumous reproduction (PHR.) In sum, PHR entails the use of genetic material from deceased parents to conceive children after their deaths. This usually means a woman will opt to become artificially inseminated with a husband or partner’s sperm retrieved while the man was in a coma or vegetative state: however, it may also include the fertilization of a woman’s eggs, frozen while she was alive, and gestated in a surrogate mother. Even frozen embryos of two deceased parents (a mother and father) might be “adopted” and implanted into a female relative or another recipient, who subsequently gives birth to a child whose biological parents are no longer alive. This process also facilitates the possibility of posthumous grandparenthood, and indeed, some parents whose adult children have died may seek out PHR technologies (include allied technologies such as surrogacy) to produce grandchildren.

Israel is one of the few countries that permits some forms of PHR, and it is a progressive nation in terms of reproductive technologies: its state health system covers the costs of ARTs (assisted reproductive technologies) for couples who have difficulty conceiving. Although Israel does not permit all forms of PHR, it does allow for the collection of a man’s sperm upon a wife’s request to carry his child upon his death (what the author calls the “prototype scenario.”) In this regard, Israel served as a prime location for surveying participants and testing initial ideas about the public perception of PHR: a new frontier of ARTs yet to be studied in the anthropological literature.

Through 26 semi-structured interviews with newlywed or childless couples, Hashiloni-Dolev discovered that there were some inconsistencies between the Israeli PHR policies and the participants’ understanding of PHR technologies. For instance, the government stipulated that PHR could occur via the retrieval of sperm from a dying or recently deceased father upon the wife or female partner’s instruction. The policy states that the retrieval could occur given evidence of a man’s “presumed wish” that he would want his spouse or partner to carry his child after death. However, “wish” and “consent” were interpreted differently by men interviewed for the study. The men typically stated that while they would defer to their partner’s wishes to have a child after their death, they themselves were uncomfortable with the possibility of their partners having the child and being unable to “move on” should they pass away. In this instance, while the man’s presumed “wish” might not change a woman’s decision to retrieve his sperm posthumously, it does not mean the man would “consent” to the process if he were not already dead.

Conversely, consent becomes more complicated given the circumstances that typically surround the use of PHR. The man is presumably young, such that his female partner would be able to carry his child, and would have died suddenly: thus making it nearly impossible to obtain his consent unless he had already affirmatively offered it while still alive and healthy.

There were also issues related to the family life of a child born through PHR techniques. Both male and female participants worried about the emotional stability and security of children born out of such conditions, and expressed their concern with new policies being proposed that would allow for expanded posthumous grandparenthood rights. The participants believed that the decision to have children following the death of a spouse was between the couple, and was not between other family members. Likewise, many participants worried about the birth of a child as a living shrine to the deceased, rather than as a new and autonomous member of the family.

In these responses, it is clear that while both biomedical technologies and governmental policies may enable PHR to occur, the process is not always viewed in such liberal terms by individuals who could be most likely to use it. Posthumous reproduction thus supplies medical anthropologists and scholars of social medicine with a nuanced case of the cultural position of new technologies, and the concerns that individuals across cultures have with these new reproductive tools: particularly as they relate to consent, kinship, and the roles of parents.

 

Issue Highlight: Vol 39 Issue 3, Suicide in Rural Kenya

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When a new issue of Culture, Medicine & Psychiatry is released, we feature a series of blog posts that highlight these latest publications in our journal. The current September issue includes articles that address psychiatric conditions and the experiences of people with mental illness across cultures. Readers may access the full issue at Springer here: http://link.springer.com/journal/11013/39/3/page/1. In this issue highlight, we will discuss an article on ethnographic analyses of suicide and distress amongst three communities in northern Kenya.

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Suicide in Three East African Pastoralist Communities and the Role of Researcher Outsiders for Positive Transformation: A Case Study

Bilinda Straight, Ivy Pike, Charles Hilton, and Matthias Oesterle – Pages 557-578

http://link.springer.com/article/10.1007/s11013-014-9417-4

The authors of this article strive to establish a nuanced and ethnographically rich understanding of suicide and mental distress in an under-studied population of three distinct, yet interacting, pastoral communities in northern central Kenya. These three groups– the Pokot, Samburu, and Turkana– are engaged in intercommunity conflicts over territory and land use agreements, despite the communities’ shared and entangled oral histories. Such tensions are only exacerbated by mutual fear of raids by other groups, dearths in food available for forage, and the theft of livestock from individuals who sell the animals to finance political campaigns. Poverty is likewise aggravated by these patterns of loss and violence.

This turbulent social environment creates widespread mental distress amongst the three communities, yet individuals from each group stressed to the research team that they felt obligated to persevere despite these pressures, making admitting psychological suffering (and especially confessing thoughts about suicide) deeply taboo. Therefore, any mental health intervention would have to be responsive to the extent to which Pokot, Samburu, and Turkana culture disallow individuals from discussing or even thinking about suicide: an act which could create even more social strain on the family of the person who committed it. The researchers confirmed this inability to discuss suicide by the high rates of non-response on a survey question which asked participants whether or not they had experienced suicidal thoughts.

Suicide thus proves to be a unique case for anthropological analysis because it is both driven by the social conditions of those who take their own lives, as well as disruptive to the communities in which these people lived. Its treatment by global health workers must in turn be sensitive to cultural beliefs that forbid conversation about suicide, especially in communities where the death of an individual may contribute to already extraordinary social distress.

Issue Highlight: Vol 39 Issue 3, Maya Mental Disorders in Belize

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With each new issue of Culture, Medicine & Psychiatry, we feature a series of blog posts that highlight the latest publications in our journal. This September’s issue includes articles that address psychiatric conditions and the experiences of people with mental illness across numerous cultures. Readers may access the full issue at Springer here: http://link.springer.com/journal/11013/39/3/page/1. In today’s issue highlight, we will examine a study on indigenous nosologies of mental illness amongst the Maya of Belize.

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Narrative Structures of Maya Mental Disorders

Andrew R. Hatala, James B. Waldram, and Tomas Caal – Pages 449-486

http://link.springer.com/article/10.1007/s11013-015-9436-9

To understand the compatibility of divergent medical traditions, it is first essential to describe how medical systems classify and interpret disorders in particular ways. With this aim in mind, the authors of this ethnographic study sought to develop an picture of indigenous mental illness nosology amongst the Q’eqchi’ Maya of southern Belize. They also asked how this knowledge may alternatively coexist, or compete, with biomedical concepts of suffering.

In order to learn about this indigenous medical epistemology, the authors worked with the Maya Healers’ Association, a professional, self-regulated group of twelve healers who maintain a garden of medicinal plants for research and who strive to reinvigorate traditional medical practice in Belize. Across ninety-four interviews with healers, the authors uncovered four illness categories that the participants used to describe the roots of mental illnesses: “thinking too much,” fright, the day of birth, and spirit “attacks.”

These descriptions are sometimes cross-compatible with DSM-V nosologies, as the researchers discovered that “thinking too much” was also listed as a symptom in biomedical models of mental illness. However, unlike the DSM-V, Maya healers tended to characterize overthinking as a “genre” of illness experience rather than as a discrete symptom. Maya healers also characterize mental illnesses as existing within the heart, the mind, and the spirit: thereby expanding the implications of mental illness beyond brain physiology, the proximate explanation employed by biomedical psychiatry.

The authors conclude that it is essential to understand the similarities in the two nosologies to facilitate collaboration between indigenous and biomedical healers, but add that both groups must also be aware of the differences in classificatory schemes that they use to interpret mental illness. In this way, people with mental disorders in Belize may best receive care that accounts for all of the ways they might seek care and understand their illness across the boundaries of medical systems.

Issue Highlight: Vol 39 Issue 3, Depression & Psychiatry in Iran

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With each new issue of Culture, Medicine & Psychiatry, we feature a series of blog posts that highlight the latest publications in our journal. This September’s issue features articles that address psychiatric conditions and the experiences of people with mental illness across cultures. The articles span studies in India, the United States, East Africa, Iran, and Belize. Readers may access the full issue at Springer here: http://link.springer.com/journal/11013/39/3/page/1. In this issue highlight, we will explore the emergence of public discourse about mental illness, suffering, and political struggle in Iran.

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Writing Prozak Diaries in Tehran: Generational Anomie and Psychiatric Subjectivities

Orkideh Behrouzan – Pages 399-426

http://link.springer.com/article/10.1007/s11013-014-9425-4

Behrouzan’s study began upon noticing young Iranians discussing mental illness in blogs and in public forums in the early 2000s. At the same time, the author examined unpublished public health records maintained by the state, and noticed that there was a sharp rise in the prescription rate of antidepressants in the mid to late 1990s. This pattern correlated with a shift in the understanding of suffering: during the Iran-Iraq war of the 1980s, PTSD and anxiety disorders were considered the most pressing mental health concerns, but these illnesses became supplanted by a shared culture of loss and hopelessness amongst young Iranians in the period following the war.

Unlike the narrative of depression in other places, however, Behrouzan found that the Iranian category of depreshen held deep political meanings. The illness category reflected the condition of those unable to publicly mourn for friends and family who may have been executed as political prisoners, or to process grief about continued political unrest that seemed to have no resolution, or to understand the loss of a parent during wartime as a young child. As one Iranian blogger described, “our delights were small: cheap plastic footballs, cartoons and game cards… But our fears were big: what if a bomb targets our house?” Thus depreshen becomes an experience of suffering that reverberates throughout a generation.

However, Iranian psychiatry responds to this condition outside of its cultural context, and continues to treat depreshen as an individual patient pathology that can be understood in biological terms. By biomedicalizing depreshen in this way without understanding its connection to political struggle, Iranian psychiatry minimizes suffering and “takes away subjects’ abilities to interpret and/or draw on their pain as a political resource.” When we interpret depreshen from the perspective of patients, therefore, we gain a nuanced view of suffering that is at once culturally specific and politically powerful.