Japan is a mystery to many in the West. Japanese psychiatry has been particularly perplexing - and depression is its heart of darkness. The Japanese didn't do Freud or Prozac; and psychotropic drugs promoted institutionalisation there while they led to deinstitutionalisation here. And until very recently, in the face of one of the highest suicide rates in the world - three times that of the UK - the Japanese haven't had depression, either. "Suicides of resolve" have been an existential issue. Instead of depression, there has been an apparent aesthetic of melancholy (wabi-sabi), with men more affected than women.
For decades, Western authors have struggled to make sense of this difference, given that Japanese psychiatry has been ostensibly Western in form for more than a century. They have inserted accounts of Morita therapy to fill the Freud-shaped gap. They have outlined syndromes such as shinkeishitsu (anxiety disorder) and claimed these as the equivalents of Western disorders. They have suggested that amae (dependency) accounts for the different clinical trajectory of disorders in Japan. But rather than clarifying anything, these accounts have served only to deepen the mystery.
Medical anthropology, with its propensity to theoretise and problematise issues and refer endlessly to other work and concepts with which the reader will not be familiar, is for many outsiders almost as impenetrable as Japanese psychiatry. Putting the two together should be a recipe for disaster, but in Junko Kitanaka's hands, this book is instead a triumph, perhaps even a classic.
She begins with Oshima Ichiro, a young advertising executive whose family was awarded about £1 million in 2000 by Japan's Supreme Court after his death by suicide nine years earlier was blamed on overwork. Then, through a series of vignettes, Kitanaka handles issues of temperament and personality, neurosis and malingering, genetic determinism, somatism and biological reductionism. These are issues that both Western and Japanese medicine have had to grapple with, and Kitanaka's handling of them sheds light on both approaches. But this is not a book about concepts. The people outlined in its pages give it life. Far from being alien, these patients, doctors and bureaucrats are all too human. This is not a book about the Other, but about ourselves - Western or Japanese.
In the opening chapters, Kitanaka covers the evolution of Japanese ideas through its artists and other public figures. The power of her approach becomes more apparent in the second half of the book, where, with the sure touch of a short-story writer, she presents the dramas of those affected by "depression" of various sorts, their interactions with clinicians and the impact of a legal and bureaucratic apparatus on both. These men and women hover in front of us, caught in the light of her sympathy, against a dimmer backdrop of concepts, historical ironies and economic forces.
Kitanaka catches a moment in time rather than an abstract message - and it is a moment that the West faces, too. For more than a decade Japan has been swamped by a recession that has now reached our shores, and this tsunami shapes her story - how economic pressures led to overwork, suicides, the emergence of depression and growing ambivalence among psychiatrists as their traditional approaches have been eviscerated, with no clear sense as to whether social change, pharmaceuticalisation or other forces are to blame. In showing how depression and the welfare system emerged as an answer to the problem but in turn have been portrayed as the problem, she outlines many of the dilemmas of the global economy.
Another striking Japanese trope that emerges from these pages is a message that you cannot change personality, and that getting people to explore the self is either arrogant or foolish, as it opens them up to colonisation. Exploring social forces, however, is fair game - unless you're a woman. There are echoes here of the 1950s; Japanese women resent their lot a good deal more than men, but for them changing the system is even less of an option.
Will "the psychiatric language of depression...help people to address the fundamental question of modernity - that is, if their relentless quest for personal advancement through the current system is really the way to pursue happiness"? Kitanaka makes this question live.
Depression in Japan: Psychiatric Cures for a Society in Distress
By Junko Kitanaka
Princeton University Press
264pp, £52.00 and £20.95
ISBN 9780691142043 and 2050
Published 24 October 2011