Lang Jansen Appropriating Depression

This article was downloaded by: [Bayerische Staatsbibliothek]On: 11 July 2013, At: 00:34Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Medical Anthropology: Cross-CulturalStudies in Health and IllnessPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/gmea20

Appropriating Depression:Biomedicalizing Ayurvedic Psychiatry inKerala, IndiaClaudia Lang a & Eva Jansen aa Institute of Social and Cultural Anthropology, Ludwig-Maximilians-University, Munich, GermanyAccepted author version posted online: 19 Mar 2012.Publishedonline: 03 Dec 2012.

To cite this article: Claudia Lang & Eva Jansen (2013) Appropriating Depression: BiomedicalizingAyurvedic Psychiatry in Kerala, India, Medical Anthropology: Cross-Cultural Studies in Health andIllness, 32:1, 25-45, DOI: 10.1080/01459740.2012.674584

To link to this article: http://dx.doi.org/10.1080/01459740.2012.674584

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/loi/gmea20

http://www.tandfonline.com/action/showCitFormats?doi=10.1080/01459740.2012.674584

http://dx.doi.org/10.1080/01459740.2012.674584

http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/page/terms-and-conditions

Appropriating Depression: Biomedicalizing AyurvedicPsychiatry in Kerala, India

Claudia Lang and Eva Jansen

Institute of Social and Cultural Anthropology, Ludwig-Maximilians-University,Munich, Germany

The appropriation of biopsychiatric concepts such as depression, and their reframing in clinical and

academic discussions, are important parts of the revitalization of bhut vidya as Ayurvedic psychiatry.

Drawing on ethnographic fieldwork conducted in Kerala from 2009 to 2011, in this article we

explore the process and the controversies of translating and correlating the biopsychiatric notion

of depression, as a discrete and biologic pathological entity, with Ayurvedic notions of body, mind,

and mental distress. Depression, conceptualized as a neurochemical imbalance, is, we argue, rela-

tively compatible with Ayurvedic notions of a fluent body and mind, and so is easier to correlate

with Ayurvedic concepts of dos_ic imbalances and blockages of channels than the former psychoana-

lytically dominated model of depression. The appropriation of depression within Ayurvedic dis-

course challenges the dichotomy of universal and culture-specific disorders, and this has a

significant impact on mental health programs in Kerala.

Keywords Ayurveda, biomedicine, depression, India, psychiatry

The World Health Organization (WHO) states that depression will be the world’s second most

prevalent health problem by the year 2020 (Desjarlais et al. 1995; Murray and Lopez 1996;

WHO 2009). In the South Indian state of Kerala, there is a very high reported number of people

suffering from depression; it is often cited as a major cause for the high rate of suicides in the

state, which is, according to different sources, twice or even three times the national average

(Halliburton 1998; Chua 2009). Health education campaigns and awareness programs as tech-

niques of biopsychiatric governmentality disseminate the biomedicalization, individualization,

and pharmaceuticalization of emotional distress and despair, and degrade local sociocentric

and cosmological explanatory models as superstitious and discordant with modernity. In Kerala,

emotional suffering, once dealt with primarily by family elders, religious experts, and vaidyas

CLAUDIA LANG is a postdoctoral research fellow in the Institute of Social and Cultural Anthropology, Ludwig-

Maximilians-University of Munich, Germany. Her interests include medical anthropology, psychiatric anthropology,

Ayurvedic medicine, religious healing, and South Asia. EVA JANSEN is a PhD student in the Institute of Social and Cul-

tural Anthropology, Ludwig-Maximilians-University of Munich, Germany. Her research interests include complementary

and alternative medicine and its relationships to allopathic practices in India as well as in Europe. Currently she is work-

ing on her dissertation on Naturopathy in South India.

Address correspondence to Claudia Lang, Institute of Social and Cultural Anthropology, Oettingenstrasse 67, 80538

Munich, Germany. E-mail: [email protected]

Medical Anthropology, 32: 25–45

Copyright # 2013 Taylor & Francis Group, LLC

ISSN: 0145-9740 print/1545-5882 online

DOI: 10.1080/01459740.2012.674584

Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

(Ayurvedic healers), is now increasingly handled by biomedical experts, thereby transforming

vis_adam (Malayalam: depressed mood) from an existential, moral, religious, or humoral

problem into a biomedical condition.

Mental health experts link the rise of depression causally to Kerala’s fast socioeconomic

transformations. These include the decline of the joint family system, the discrepancy between

high standards of education and low employment, and labor migration to the Gulf states, result-

ing in ‘‘gulf depression’’ of these migrants and of the women left behind. Moreover, the gap

between high ambitions and expectations, and often harsh socioeconomic realities, the heavy

consumption of alcohol, and pressure exerted on children by the school system, also reportedly

contribute to depression. In a state well known for its health care and general high development

indicators, depression is a challenge. Like suicide, the high rate of depression shows the short-

comings of the ‘‘Kerala model’’ (Halliburton 1998) and indexes the disappointment over the

unfulfilled political and social promises in the face of reality (cf. Chua 2009).

Halliburton (2005) showed that ‘depression’ and ‘tension’ have to a great extent replaced pos-

session as an idiom of distress. Although this is true for possession and for other ‘‘exogenous’’(Smith 2006) models like sorcery (kaivis

_am, mantravadam) and malevolent cosmological

constellations, these local categorizations of mental distress not only persist (Halliburton 2005;

Smith 2006) but also are often hybridized with biopsychiatric notions to which they are linked

(Tarabout 1999). Depression is either used as an English word or translated into the Malayalam

term vis_adam or medicalized as vis

_ada rogam (the disease depression or depressive disorder) as a

form of mental disease (manasika rogam). Vis_adam is used in the sense of persistent despon-

dency, low mood, sadness, and avolition, or more psychologically, as a dilemma in which

the thinking process is blocked and for which no solution can be found. Indian psychiatrists—

ayurvedic and biomedical ones alike—and psychologists often cite the Bhagavadgita with regard

to depression and what is sometimes called ‘Indian psychology’ and ‘Indian psychotherapy’

(Kuppuswamy 1959; Krishnamurthy 1964). The warrior Arjuna’s vis_ada yoga, his moral

dilemma in light of the fact that he should enter the war against his teachers and closest relatives,

and the ‘counseling,’ by his charioteer Krishna, on his moral duty, and his detachment from the

consequences of his actions in the Bhagavadgita, are described as an example of the ‘Indian’

approach to depression.

APPROACHING DEPRESSION

In this article we focus on the biopsychiatric concept of depression. We neither argue for the

universality nor the cultural specificity of depression or depressive disorder, but rather explore

the processes of appropriating this globally circulating concept within what is now called

Ayurvedic psychiatry. We attend especially to the social, cultural, and political context of

Ayurvedic psychiatry in the local reality of Kerala today. Much has been written on whether

depression should be seen as a universal category—albeit with different manifestations in differ-

ent cultural contexts—or as a culture-specific or even a culture-bound syndrome (Kleinman and

Good 1985; Kirmayer 2001; Kirmayer and Jarvis 2006; Jadhav 2000; Raguram et al. 2001).

Among cultural psychiatrists, the prominent debate relates to ‘somatization,’ that is, the tendency

of South Asian patients to present presumed psychiatric disorders through somatic symptoms

(e.g., Kleinman and Good 1985; Kirmayer 1997; Raguram et al. 1996; Patel und Sumathipala

26 C. LANG AND E. JANSEN

Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

2006; Kohrt 2005). Somatization theory has been criticized by anthropologists of South Asia for

assuming that depression is universal, and for ignoring the relationship between symptom pres-

entation, meaning, and local patterns of resort. Somatization theory, critics argue, creates a split

between the ‘imaginary’ illness and the ‘real’ disease (Langford 2002:235; see also Kirmayer

1988). Anthropologists and cross-cultural psychiatrists have also stressed the disjunctures

between Western psychiatric discourse and culturally embedded idioms of distress and healing

(Kleinman and Good 1985; Weiss, Raguram, and Channabasavanna 1995; Summerfield 2008).

For this reason, some anthropologists and psychiatrists have suggested giving up universal con-

cepts like depression altogether, and instead adopting local ways of expressing distress (Nichter

1981; Obeyesekere 1985; Weiss et al. 1995; Bhugra and Mastrogianni 2004; Ecks 2005;

Summerfield 2008).

Other authors have critically analyzed the relationship between the pharmaceutical marketing

of antidepressants and the postulated rise of depression (Healy 2004; Kirmayer 2002; Ecks 2005;

Applbaum 2006; Kitanaka 2006; Horwitz and Wakefield 2003), and the promise of demargina-

lization and ‘pharmaceutical citizenship’ (Ecks 2005; Rose 2003) through antidepressants. In

this context, ‘traditional knowledge’ such as Ayurveda is also ‘‘taken to the market’’ (Bode2006) of depression, in the form of modern pills and other means of administration of drugs

(Bode 2006; Banerjee 2008). These debates, which have shown that depression is not a discrete

biological process in an individual patient but rather a complex intertwining of biological, exis-

tential, social, and economic processes (Storck, Csordas, and Strauss 2000), contribute toward

understanding the appropriation and local reality of depression.

One factor much neglected, however, is the process of appropriating, translating, and refram-

ing depression within indigenous medical knowledge systems. As scholars studying Ayurveda

(Leslie 1992; Langford 2002; Meulenbeld 2008; Wujastyk and Smith 2008) have shown, the

biomedicalization of Ayurvedic concepts was important in the revivalism of Ayurveda from

the eighteenth century, and the adaptability of Ayurveda and its potential to produce new knowl-

edge in dialogue with biomedicine, along with its cultural basis in India and in other South Asian

countries (for Nepal, see Cameron 2008), is a major cause for its survival subsequently

(Meulenbeld 2001). Avurvedic theory was biomedicalized since early colonial times (Leslie

1992; Langford 2002), and Ayurvedic education was professionalized and institutionalized in

India in the nineteenth century (Brass 1972; Jefferey 1988; Leslie 1992; Wujastyk 2003; Wujas-

tyk and Smith 2008). However, the appropriation and translation of biopsychiatric disorders

within Ayurveda is more recent (Langford 2002), related to the institutionalization of Ayurvedic

psychiatry. Extending Good’s (1992) proposal for medical anthropologists to study the social

and cultural constructions of psychiatric disease categories to other medical systems, in this arti-

cle, we explore the reframing of depression as a disease category in relation to the revitalization

of Ayurvedic psychiatry as an institutionalized subdiscipline of Ayurveda.

Next, we discuss the interaction of local and global psychiatric categories in the process of

negotiating, appropriating, and translating the global concept of depression within Ayurvedic

psychiatric discourse in Kerala. We focus on institutionalized Ayurvedic psychiatry as the pro-

cess of appropriating the concept of depression is most obvious in these contexts. To address this

question, we first explore the ‘scientification’ of Ayurvedic psychiatry in Kerala with a special

focus on the two forms of unmada (mental disorder)—dos_a unmada and bhuta unmada—which

are described in the classical texts and are still relevant in contemporary Ayurvedic theory

and clinical practice. We then analyze the correlations clinicians make between Ayurvedic

APPROPRIATING DEPRESSION IN AYURVEDIC PSYCHIATRY 27

Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

and biopsychiatric categories and etiologies. Finally, we discuss some implications of these

findings for mental health services in Kerala and for global mental health theories.

METHODS

The data presented here are drawn from ten months of ethnographic fieldwork from 2009 to

2011. The fieldwork was conducted first at the Government Ayurveda Mental Hospital

(GAMH), and then at the Department of Kayachikitsa (general medicine) at an Ayurveda col-

lege, which offers a postgraduate course of psychiatry and a psychiatric outpatient service. Both

are located in Kottakkal, Malappuram district. The third site of the fieldwork was at two private

clinics of an Ayurvedic clinician who specializes in Ayurvedic psychiatry in the mostly Christian

town of Ankamally, Ernakulam district. In these three settings, we interviewed clinicians and

students specializing in Ayurvedic psychiatry, observed and recorded clinical encounters, and

discussed ‘cases’ before and after the encounters. We collected narratives of patients and their

caretakers, observed classroom discussions in the college, and analyzed patients’ charts. We also

interviewed several general Ayurvedic clinicians and college teachers. Finally, we analyzed

media reports on the Ayurvedic approach to depression.

The Government Ayurveda Research Institute of Mental Diseases or Government Ayurveda

Mental Hospital (GAMH), as it is popularly known, is situated in the small town of Kottakkal in

the mostly Muslim Malappuram district (cf. Halliburton 2009; Giguere 2009). The hospital is

located in a large, modern building. It provides free wards and user-pays wards for 50 inpatients,

and has a daily outpatient facility that attracts patients from different social and religious back-

grounds from both nearby villages and towns, from other parts of Kerala, and even from other states.

The Department for General Medicine of the P. S. Varier Ayurveda College in Kottakkal offers

outpatient services for manasika rogam (mental disease) on a daily basis, with each day reserved

for a specific disorder. The facility—the Manashanti Counseling Unit—treats patients mostly

from the districts of Malappuram and Kozhikode, irrespective of class, caste, religion, and

age, with almost equal numbers of women and men. Most patients are managed by some 30

postgraduate students specializing in these specific disorders, sometimes with the help of their

teachers. Here, we participated in the outpatient departments (OPDs) for ‘‘vis_adam, tens

_an, utkan-

tham’’ (depression, tension, anxiety) offered on Tuesdays, and the general ‘‘manasika rogam’’(mental disease) offered on Wednesdays. After consultations, we often had the opportunity to

discuss cases with the students and the clinician and teacher heading the OPD.

The two private clinics of Dr. Tom Paul,1 which he named (in English) the Centre for

Ayurvedic Treatment, Counseling and Psychotherapy especially for Psychosomatic Diseases,

and the Arogya and Manovikas Kendra (center for health and mental development; named in

Malayalam), are two of the very few private clinics specializing in Ayurvedic mental health care

in Kerala. Although most of his patients are Christian, he also treats Hindus and Muslims,

mostly from the middle class, with slightly more women than men, from around 20 to 50 years

old. At his clinics, participant observation meant that the first author (C.L.) was integrated in the

clinical encounters, and was presented to patients as a doctor from Germany who wanted to learn

about Ayurveda. Although not a clinician, C.L. was sometimes given a medical device such as a

stethoscope by the attending doctor in order to make her appear like a medical professional. In

other rare cases, he would ask C.L. to give counseling to some of his patients. Many of the


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

explanations Dr. Tom Paul gave, and the discussions we had regarding depression, were

included in discussions he had had with his patients and their caregivers, as part of the clinical

encounter. Moreover, C.L. had a lot of discussions with these inpatients, outpatients, and family

members who accompanied them as ‘bystanders.’ At the GAMH, the data are drawn from inter-

views with clinicians, their patients and caretakers, from patient charts, and from discussions

between clinicians and Bachelor of Ayurvedic Medicine and Surgery students from all over

Kerala, who did their obligatory two months of ‘house surgency’ (internship) there. At the

GAMH, participant observation of the ward ‘rounds’ and outpatients’ clinical encounters was

not permitted, as we were not Ayurvedic students or clinicians.

The appropriation of the biopsychiatric concept of depression—of correlating it to Ayurvedic

concepts and of biomedicalizing Ayurveda—undoubtedly occurs in Ayurvedic academic discus-

sions, workshops and conferences, in classroom debates and research theses, in the media, and in

clinical encounters with patients in Kerala. Yet our initial questions regarding the Ayurvedic

approach to depression also influenced the way our interlocutors reflected on the relation of

depression and Ayurvedic concepts.

THE SCIENTIFICATION OF AYURVEDIC PSYCHIATRY

Ayurvedic psychiatrists place revitalized and institutionalized Ayurvedic psychiatry in an epis-

temological and discursive landscape that is marked by the biopsychiatric discourse on mental

ailment on the one hand, and by vernacular idioms of distress such as sorcery, possession, and

attacks by evil spirits on the other. The growing need for a treatment of common mental disor-

ders such as depression, as well as representations of Ayurveda as an ancient Indian and modern

science able to treat biomedically defined diseases, has facilitated an institutionalized and

secularized form of Ayurvedic psychiatry. Although there have always been traditionally trained

vaidyas who specialized in the treatment of mental disorders in Kerala, the development of a

distinct and institutionalized Ayurvedic psychiatry, mirrored in the compartmentalization of

mental and physical diseases in theory and practice, is a recent phenomenon.

At the GAMH, we were introduced to the theory and practice of Ayurvedic psychiatry, or

bhut vidya, by the four practicing doctors who emphasized both their modernity and their pure

Ayurvedic approach to mental diseases (cf. Halliburton 2009; Giguere 2009). Doctors explained

that bhut vidya or graha cikitsa2 is one of the eight branches of Ayurveda. What is understood as

Ayurvedic psychiatry today draws from the sections on dos_a unmada (mental illness related to a

dosic3 or physiological derangement) and bhuta unmada (mental illness related to bhuta) inCaraka Sam

_hita, Susruta Sam

_hita, and Vagbhata’s As

_t_a _nngahr

_daya (Zimmermann 1989;

Langford 2002; Halliburton 2005; Smith 2006; Giguere 2009; Weiss 2010), reinterpreted in a

secular and scientific idiom. In the sections on dos_a unmada, mental illnesses (manasika

rogangal) are described as physiological disorders.

In the sections on bhuta unmada, in contrast, mental illness is described in relation to super-

natural entities. In the middle of the twentieth century, in an effort to biomedicalize Ayurvedic

categories, bhuta were interpreted as bacteria, viruses, and fungi, and bhut vidya was categorized

as bacteriology in some textbooks and by some clinicians (Langford 2002:87), although not all

physicians would agree with this. Later, the sections on bhut vidya in the Sam_hita-s became

reinterpreted and integrated into what is today called Ayurvedic psychiatry by college-trained


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

Ayurvedic practitioners. The latter dissociate bhut vidya from its presumed false association with

demonology or exorcism, a fact that ‘‘the lay people and most of the Ayurvedic physicians who

are not working in psychiatry don’t know,’’ Dr. Sundaran complained. Indeed, a number of

patients and caretakers who come for Ayurvedic treatment associate mental illness either with

possession or with sorcery, a fact that becomes clear from numerous interviews with patients

and caretakers regarding their explanations and patterns of resort for mental distress. Most have

a long history of seeking diagnosis and treatment with astrologers, religious healers such as

Hindu mantravadi, priests, Muslim thangal, or at religious healing centers, as well as biomedical

and Ayurvedic practitioners. Most clinicians at the GAMH sharply differentiate between the

dos_a and the bhuta or graha forms of mental illness, although this distinction and the interpret-

ation of graha unmada are not uncontested. Most patients are diagnosed in dos_a terms; only a

few are treated on the basis of a bhuta or graha diagnosis.

In the Ayurvedic psychiatry seminars at the College, students and professors correlated physio-

logical mental illness (dos_a unmada) with neurotic disorders and graha unmada with psychotic

disorders. In this sense, graha are thought of as the proportion of psychotic features in a patient.

Dr. Sundaran, in his Malayalam-written standard work on Ayurvedic psychiatry, Treatment ofMental Diseases in Ayurveda (1993), translated bhuta unmada or graha unmada as ‘personality

disorder.’ In this sense, bhuta unmada, in the classical texts only treatable with religious ritual

remedial measures, are medically ‘untreatable’ (Sundaran 1993). Likewise, Dr. Tom Paul differ-

entiates physiological mental illness from personality disorder, with the latter untreatable by

Ayurvedic medicines and procedures but able to be treated by psychotherapy (sattvavajaya) orreligious therapy (daivavyapasraya cikitsa), which he mainly understands in terms of Christian

deliverance prayers or exorcism. Dr. Tom Paul and one other practitioner from a Christian lineage

of vaidyas, both practicing in mostly Christian areas of Kerala, trace some cases of depression in

their practice not back to physiological derangements but rather to attacks or possession by evil

forces, and consequently they send these patients to Christian priests practicing deliverance prayers

or exorcism. The understanding of bhuta or graha unmada either as ‘psychotic features’ (Dr.

Rasheed) or as ‘personality disorder’ (Dr. Sundaran, Dr. Tom) transfers causality from exogenous

causes into internal configurations conforming to a modern psychiatric view of mental disorders.

While in their framing as ‘microorganisms,’ bhuta are part of the ‘etiological landscape’

(Langford 2002:88), for the doctors and students at the GAMH and the Ayurveda College, bhuta

or graha are not causative factors, but simply observable behavioral or personality traits based on

similarities to certain mythological figures or characters. Where Ayurvedic psychiatrists could eas-

ily describe an etiology for mental illness caused by vitiation of kapha unmada (a despondent,

phlegmatic state) and other physiological forms of mental illness, as discussed next, they have dif-

ficulties developing an elaborate etiology for the redefined graha. While in the classical texts, graha

did indeed mean ‘‘possession,’’with the violation of social and religious norms being the causative

factors (Sundaran 1993:32–33), the modern understanding of graha is as ‘‘similarities’’ with‘‘guilty consciousness’’ (Sundaran 1993:32); the violation of these rules is the only accepted cause.

The etiology for mental illness caused by the vitiation or aggravation of the dos_a—wind, bile,

and phlegm—is well-defined. Practitioners explain different levels of causation (nidana) of

depression or related Ayurvedic categories like kapha unmada. Dr. Rasheed from GAMH

elaborated on the causal chain of mental illness caused by the aggravation of phlegm (kapha

unmada) as follows. External factors such as tension, bereavement, loss, or a wrong diet can

trigger the disease. Passions and emotions such as sadness, grief, anger, lust, or the desire for


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

material goods, resulting from too much attachment, from false sensory perceptions, or a faulty

judgment (praj~nnaparadha), also cause dos_a unmada. In contrast to Western theories, all intense

emotions, passions, and desires are considered to be causative factors of mental disorders.

In order to develop kapha unmada, a certain psychic predisposition expressed in the termin-

ology of the three gun_a (basic qualities) is required. While sattva indicates a healthy or pure

mind, rajas (activity and change) and tamas (darkness, heaviness, plumpness, ignorance) are

viewed as nocuous qualities that can cause mental illness if pathologically increased. In this

sense, deficient sattva quality constitutes the predisposition of all mental disorders, whereas

mental strength (sattvabalam) prevents them (cf. Giguere 2009). Some practitioners explained

it the other way around: the aggravation of kapha or phlegm leads to a derangement of con-

sciousness, intellect, and memory, which again increases the proportion of rajas and tamas. In

the case of kapha unmada, the proportion of tamas is increased. Only in an hı-na sattva (too little

sattva) predisposition, certain external factors can lead to a mental disease. The dos_a, which is

predominant in the body of the patient at the time of the triggering external factor, determines the

manifestation of the disease as wind, bile, or phlegm forms of mental illness. Due to the mutual

influence of the physical (sarı-raka) and the mental (manasika) dos_a, an excess of tamas

facilitates the pathological aggravation of phlegm in the ‘mind-carrying channels’ (manovahasrotas).

The appropriation of depression is also the creative integration and transformation of instru-

ments to quantitatively measure the degree to which the disorder is affecting an individual. In

order to evaluate patients according to assumed authentic Ayurvedic criteria of mental health

for research as well as for diagnostic ends, students of Ayurvedic psychiatry in Kottakkal use

two Ayurvedic rating scales, developed by former students of the college and based on the

descriptions of the three gun_a (basic qualities) collected from Caraka Sam

_hita, Susruta Sam

_hita,

and As_t_a _nnga Hr

_daya. If depression is connected with anger, rajas is increased. In the rating

scales, rajas and tamas as predispositions of mental disorder become measurable indices of

the degree of mental health or disorder in a patient.

The Tamas Rating Scale (TRS; Table 1) encompasses nine items and Rajas Rating Scale

(RRS; Table 2) thirteen items, with symptoms ranging from zero (absence of symptoms) to three

(severe presence of symptoms) that indicate the degree of tamas and rajas respectively. TRS asks

about depressive states (vis_aditva), belief in God (nastikyam), and the degree of nihilism, guilty

conscience (adharması-lata), communication (buddhinirodha), and lack of insight into the dis-

ease (aj~nnana), with nonmedical explanations ranking lower than the acknowledgement of suffer-

ing from a medical disorder. Further, inquiries are made regarding retardation of speech

(durmedhastva), decreased interest in activities (akarması-lata), disturbed sleep, and deviant opi-

nion (vipratipatti). Items in RRS relevant to depression are the perception that life is miserable

(duh_khabahulata), disturbed relationships with family members and colleagues ‘due to ego’

(aham_karam), and anger or expression of emotions (krodha). The TRS in particular resembles

biopsychiatric rating scales like the Hamilton Rating Scale for Depression (HRSD). Items

included in HRSD such as depressed mood, feelings of guilt, insight, work, and activities are

reflected in TRS. However, students emphasized that their Ayurvedic scales were not developed

in concordance with modern tools, but are purely Ayurvedic and based on short verses in

Ayurvedic classics that describe the features of the three gun_a. Although some professors criti-

cize Ayurvedic rating scales as superficial they are regarded as important tools that mirror the

complexity of the Ayurvedic approach much better than do the HRSDs and others instruments.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

TABLE 1

Tamas Rating Scale

1. Vis_aditva

Not feeling depressed �0

These feelings indicates only on questioning �1

These feeling states spontaneously reported verbally �2

Communicates feeling states non verbally �3

2. NastikyamFull faith in God �0

More faith in God �1

Little faith in God �2

No faith in God �3

3. Adharması-lataAbsent �0

Self-blaming �1

Ideas of guilt and rumination of the past sinful deeds �2

Feels that present illness is a punishment �3

4. BuddhinirodhaAble to communicate �0

Difficult poses in between �1

Broken words, word repetition, and physical tension �2

Unable to communicate �3

5. Aj~nnana

Acknowledges being depressed and ill �0

Attribute causes of illness to bad food, climate, overwork, virus, need for rest, etc. �1

Slight awareness of being depressed and needing help but denies it at the same time �2

Denies being ill at all �3

6. Durmedhastva

Normal speech and thought �0

Slight retardation at interview �1

Obvious retardation so that interview is difficult �2

Complete stupor �3

7. Akarması-lata

Interested in activities �0

Show little interest in activities �1

Show no interest in activities �2

Show no interest in daily routine �3

8. Normal sleep

Normal sleep at night �0

Normal sleep þ0�1 hour sleep �1



9. Vipratipatti

No individual opinion about anything �0

Express the opinion occasionally �1

Always express the opinion in each matter �2

Express the opinion contradictory to others �3


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

TABLE 2

Rajas Rating Scale

1. Duh_khabahulata

Doesn’t feel life is a misery �0

Often feel that life is a misery �2

Always feel that life is a misery �3

2. �AAtanası-latah_Normal movements �0

Shows increased movements �1

Restlessness �2

Always moving around �3

3. Adhr_ti

Fully attentive �0

Often difficult to concentrate �1

Most of the time difficult to concentrate �2

Not attentive at all �3

4. Aham_kara

Good relation with family members and colleague �0

Quarrels with family members and colleagues �1

Do not obey the superiors �2

No relationship with other due to ego �3

5. Anr_tikatva

Tells lies for apparent reason �0

Tells lies for simple reason �1

Always having a tendency to lie �2

Always gaining pleasure in telling lies �3

6. Akarunya

No tendency for harming anybody �0

Occasionally behave cruelly to others �1

Always cruel to others and harming the pets �2

Self-harming behavior and is a threat to others �3

7. Dabha

No self-boasting �0

Self-boasting to friends and family members �1

Self-boasting to strangers and superiors �2

Self-boasting to everybody �3

8. Maninam

Normal self-confidence �0

Overconfidence �1

Overconfidence and attempting for dangerous Activities �2

Doing dangerous activities without any fore thinking �3

9. Krodha

Appropriate expression of emotions �0

Excessive anger or happiness for small reasons �1

Displays happiness or anger without any reasons �2

Inappropriate and excessive expression of emotions �3

(Continued )


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

In the Ayurveda College and in the private clinic of Dr. Tom Paul, the terms ‘depression’ or

‘mild’ or ‘moderate depression’ are written on the patient charts. In contrast, doctors at the

GAMH use either purely Ayurvedic Sanskrit terms such as kapha unmada or a combination like

‘‘depression (kapha unmada)’’ on patients’ charts. Graha unmada, which in rare cases are used in

internal diagnostics, are never used in official documents or in doctors’ consultations with

patients and families. Doctors at the GAMH argue that bhuta could be ‘‘misunderstood’’ bypeople other than Ayurvedic psychiatrists as being ‘‘related to demons and exorcism,’’ therebydiscrediting Ayurvedic psychiatry as unscientific, superstitious, and antiquated. The more

universal and ‘‘context-free’’ (Halliburton 2005) dos_a-based and biopsychiatric categories are

regarded as more scientific, and so the graha-based diagnoses are avoided in official documents

because they are not regarded as scientific.

The overall aim of contemporary Ayurvedic psychiatry is to purify Ayurvedic psychiatry

from its nonscientific and superstitious connotations and institutionalize it as a scientific

approach to psychiatric disorders. Bhut vidya and dos_a-based concepts of mental illness are

therefore revitalized and translated by adopting biopsychiatric categories, giving them a claim

to modernity and contemporaneity.

THE QUEST FOR CORRELATIONS: DEPRESSION,KAPHA UNM�AADA, AND VIS

_�AADAM

In order to ‘‘make an Ayurvedic contribution to the overall debate on depression,’’ as one collegestudent expressed it, Ayurvedic psychiatrists engage the global biopsychiatric debate on mental

TABLE 2

Continued

10. Kami

Normal desire for the likings �0

Excessive desire for the likings �1

Strong desire for the likings �2

Do mischievous activities for an achievement �3

11. Durupacaratah_Satisfied with everything �0

Dissatisfied with some things �1

Dissatisfied with most the things �2

Dissatisfied with everything �3

12. Amitabhashitva

Normal speech �0

Slightly talkative �1

Much more talkative �2

Always talkative �3

13. LolupatvaDesire for the likings �0

Desire for other’s properties �1

Try to harass others to get the wished ones �2

Will do crooked things for obtaining the wishes �3


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

diseases, the diagnostic criteria of which are standardized transnationally by the InternationalClassification of Diseases (ICD)-10 of the WHO and the Diagnostic and Statistical Manualof Mental Disorders (DSM)-IV-TR of the American Psychiatric Association.4 The hermeneutic

exegesis of the three Ayurvedic classics, Caraka Sam_hita, Susruta Sam

_hita, and As

_t_a _nnga Hr

_daya,

in light of biopsychiatric categories, is an important part of the training of Ayurvedic psychiatric

doctors. These texts are memorized and along with biomedical textbooks, form the basis of

Ayurvedic training. Rather than being considered outdated, their validity is proven by the trans-

lation into and correlation with global psychiatric concepts. Thus, the present processes of ‘‘syn-cretism’’ (Leslie 1992), ‘‘biomedicalization’’ (Langford 2002; Clarke et al. 2010), and

‘‘bricolage’’ (Giguere 2009) in Ayurvedic psychiatry is closely related to the power of definition

of global biomedicine. Yet at the same time, practitioners claim to subvert biopsychiatry by sub-

suming its disease categories into an overarching Ayurvedic theory that is supposed to have

anticipated the modern knowledge of mental disorders (cf. Langford 2002).

Engaging depression within Ayurveda means negotiating and recontextualizing different

forms of depressive disorder as elaborated in ICD-10, DSM IV-TR, and in modern psychiatric

textbooks within an Ayurvedic frame. In order to communicate with allopathic practitioners and

patients and their families, who are more familiar with biopsychiatric notions of mental illness

than with Ayurvedic terms (cf. Nichter and Nordstrom 1989; Nisula 2006), Ayurvedic practi-

tioners and students are constantly engaged in translation processes (Langford 2002). Moreover,

college students, trained in a ‘‘conceptual bilingualism’’ (Naraindas 2006:2659) of Ayurvedic

and biopsychiatric terminology, are often more familiar with psychiatric than with Ayurvedic

terms.

Dr. Tom Paul diagnoses in ICD-10 criteria first. This diagnosis is both written on the charts

and communicated to patients and caretakers. However, to find the appropriate Ayurvedic treat-

ment procedures and drugs for depression, translations and correlations with Ayurvedic physio-

logical diagnoses are necessary. Dr. Ramachandran, a general clinician and college teacher from

the Government Ayurveda College Tripunithura, Ernakulam district, emphasized the appropri-

ateness of biopsychiatric terms vis-a-vis Ayurvedic ones:

Though we are writing kapha unmada or vata unmada, our mind will think in modern terms. To

speak frankly, when we see the patients, the modern symptomatology is more effective to categorize

them. When we see a patient we can say the patient is having depression or the patient is manic. We

can easily identify the patient. But in Ayurveda psychiatry it is difficult.

When asked about the Ayurvedic concept of depression, most Ayurvedic practitioners start

by correlating severe or endogenous depression roughly with kapha unmada, that is, ‘‘mental

disorder’’ due to the aggravation of kapha. In a simplifying effort to correlate the three main

forms of unmada with ‘‘modern’’ categories of mental disorders, vata unmada is roughly trans-

lated into ‘‘schizophrenia,’’ pitta unmada into ‘‘mania,’’ and kapha unmada into ‘‘depression.’’ Inhis postgraduate thesis at the Ayurveda college, Kottakkal, Shaik Anwar (2004:43) compared

the signs or symptoms (laks_an_a) of kapha unmada, preta graha and pitre graha (graha by spirits

of the forefathers) with those of depression and concludes that ‘‘it will be more rational and

scientific to correlate depressive disorders to kaphonmada’’ (97), although some symptoms of

both forms of graha unmada can partly be compared with this diagnosis.

While Ayurvedic psychiatrists largely agree that severe or endogenous depression correlates

with kapha unmada, mild depression is related to vata vitiation at the college in Kottakkal.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

Consequently, depression is not framed as unmada but rather as an ‘‘emotional disturbance’’(one student). Vata vitiation and emotional disturbances are mutually related; grief and anxiety

can vitiate vata while vata vitiation can manifest in excessive crying, fear, and so on. On the

other hand, vata affliction can ‘‘manifest in pure somatic symptoms only’’ (Dr. Krishnan). Byframing depression as a disturbance of vata, Ayurvedic doctors elaborate their own integrated

view on ‘‘somatization,’’ which contradicts biopsychiatry’s interpretation of somatization as a

process of masking what is assumed to be psychological symptoms by expressing them in

somatic symptoms (see previous). As a vata vitiation, ‘depression’ manifests both on the mental

and the somatic level alike. Vis_adam does not require inpatient treatment but rather can be

managed by medicine (and counseling) only. In this context, the term vis_adam, while widely

used as a synonym for depression in Kerala, is described as a symptom of vata affliction, which

is characterized by excessive worries, the circulation of thoughts and sleeplessness, a depressed

mood, total fatigue of the body, mind and speech, and mild psychomotor retardation.

Dr. Rasheed summarized the difference between vis_adam and kapha unmada in the following

statement: ‘‘Vis_adam or depression is a symptom [of vata affliction], kapha unmada or depress-

ive disorder is a syndrome.’’ A postgraduate student in his third year who headed the

vis_adam-OPD on Tuesdays specified the relation of depression and vis

_adam. In Kerala, he

remarked, vis_adam is used in three different ways. First, in common language, it is used for

depressed mood. Second, vis_ada rogam is used by allopathic psychiatrists as the Malayalam

translation of ‘depressive disorder.’ Third, the emotional disturbance vis_adam is one of the

symptoms of vata disturbance listed in the classical texts. While vis_adam does not require

inpatient treatment and can be managed with Ayurvedic drugs and counseling alone, kapha

unmada must be treated further with purgatory and purifying procedures: internal (snehapana)and external (abhya _nnga) oileation of the body, sweating (svedana), therapeutic vomiting

(vamana), and nasal treatment (nasya).Dr. Tom Paul likewise relates depression to a vata disturbance when he translates ‘‘reactive

depression’’ or ‘‘agitated depression’’ into adhija unmada, that is, unmada facilitated by loss,

and, according to him, more generally by ‘‘stress and strain,’’ resulting in the vitiation of vata.

Contrary to the opinion of other Ayurvedic psychiatrists who limit this category to grief caused

by bereavement or loss of loved persons, things or ideas, adhija unmada is Dr. Tom Paul’s most

frequent diagnosis for patients with ‘reactive’ or ‘agitated depression.’ As opposed to kapha

unmada, which he describes as endogenous, inherited severe depression with the main symp-

toms of tiredness and social withdrawal that affect mainly tamasic personalities, he maintains

that patients with adhija unmada have no family history of mental problems.

However, vis_adam as a vata affliction can develop into kapha unmada. In response to the

question of how this process happens physiologically, the postgraduate student mentioned pre-

viously introduced the concept of avarana, which means that one dos_a covers or disturbs the

function of the other(s). Vis_adam, although it manifests as a vata disturbance, can be caused

by kapha avarana—the aggravation of kapha blocks the mind-carrying channels (manovahasro-tas) and inhibits the functions of vata. Depending on the degree of kapha aggravation, mild

depression as vata disturbance can develop into severe depression (kapha unmada). Dr. Nayar

specified the relationship between vata and kapha avarana, integrating the modern concept of

depression, as the manifestation of neurochemical changes in neurotransmitters. If kapha blocks

the manovahasrotas, he explained, then vata cannot pass through. Vata is responsible for the

regulation of the mind, and stimulates the connection between a sensory object (indryartha),


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

a sensory organ (indrya), the mind (manas), and intelligence (buddhi). ‘‘Modern’’ (biomedical)

doctors, he said, express the carrier function of vata in terms of neurotransmitters. Like vata,

serotonin and noradrenalin carry the information from one neuron to another. For modern as well

as for Ayurveda doctors, according to Dr. Nayar, this carrying function of vata or serotonin and

noradrenalin, respectively, is disturbed in depression. In Ayurveda, this disturbance is concep-

tualized as a blockage caused by aggravated kapha. By reducing the blockage of kapha, he con-

cluded, Ayurvedic practitioners stimulate the neurotransmitters as vata and the neurotransmitters

are functionally the same.

Dr. Krishnan related the differentiation of vata and kapha forms of depression at the

Ayurveda College to the academic engagement of international psychiatric diagnostic tools such

as ICD-10:

Academicians say it is vata, practitioners say it is kapha. . . . In depression, mainly people see that

depression is total depressed mood, withdrawal of the society, sitting lonely somewhere. That is

one angle of depression. Actually, depression has got two domains. Agitated mood is there and

depressed mood and self-withdrawal is there in depression. Two extremes are there. We can never

say depression is only depressed mood or only this [agitation]. [The] other area is also there.

Depressive patients sometimes lose their sleep, sleeplessness is there. Same time oversleep is there.

So two domains are there, either no sleep or oversleep. ICD classification, in severe depression all

extremes are there. . . . So this type of discussion comes in academy only. Practitioners feel it is a

depressed mood, keeping in silent, going sitting somewhere. That is the only depression according

to practitioners. They don’t have ICDs, they don’t have classifications. When we discuss, we discuss

all the extremes, depression has got two domains, one is kapha dominating, other is vata-dominating.

The kapha-dominating is the depressed mood and all. Vata-dominating is agitation, restlessness, no

sleep at all, self-destruction, tearing the clothes and all; that type of agitation is there. That is vata

dominant.

Dr. Krisnan’s statement that practitioners diagnose ‘depression’ mostly as kapha unmada,

while academicians differentiate between vata and kapha forms of depression, is not supported

by the ethnographic data, according to which many vaidya and Ayurvedic physicians do indeed

diagnose ‘depression’ as a vata affliction (e.g., Smith 2006:552; Langford 2002:237). Thus, his

argument is to be understood as a claim of the superiority of the scientific approach in academia,

which is characterized by relating Ayurvedic theory to biopsychiatric, ‘modern’ diagnostic tools

such as ICD-10. By differentiating vata and kapha forms of depression and relating them to

TABLE 3

Correlations Clinicians Make between Ayurvedic and Biomedical Categories

Ayurvedic Category Biopsychiatric Category

Kapha unmada Severe depression, endogenous depression

Vata vitiation (if manas is concerned) Reactive depression, mild depression, agitated depression

Vis_adam (one symptom of vata vitiation) Depressed mood, excessive worries, circulation of thoughts, etc.

Vata kapha vitiation (if manas is concerned) Moderate depression�AAdhija unmada (mental disorder due to loss) Reactive depression, agitated depression, depression due to

stress and strain

Preta graha Catatonic depression


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

ICD-nosology, this clinician and college professor claims the participation and contemporaneity

of Ayurvedic psychiatry in a modern scientific psychiatric discourse.

In sum, mild depression with mainly somatic symptoms is discussed in relation to vata and

not interpreted as unmada (mental disorder or madness), while severe depression, characterized

by the involvement of mental faculties, is related to kapha unmada, and agitated or reactive

depression to adhija unmada, mental disorder due to loss or to stress (Table 3). This differen-

tiation also has an impact on the choice of treatment.

IMPLICATIONS FOR MENTAL HEALTH POLICY IN KERALA

As common mental disorders such as depression will be a major health problem in the next dec-

ades, the WHO and global health researchers are calling for the scale up of services for mental

disorders in lower- and middle-income countries (Patel et al. 2007, 2008; Patel and Thornicroft

2009; WHO 2009). Stimulated by the demands of the WHO and in accordance with the Indian

National Mental Health Program (NMHP) of 1982, and with different District Mental Health

Programs (DMHP) since the 1990s, stakeholders of health policy in India have increased their

efforts to expand the mental health sector and, in particular, community mental health care (for

recent critiques, see Nizamie and Desarkar 2005; Jain and Jadhav 2008, 2009). These programs

entail the training of primary health personal and lay persons such as school teachers, Panchayat

members, Anganwadi workers, and occasionally ‘‘traditional healers and faith healers’’ (Bhattet al. 2007; Government of Gujarat 2003) in diagnosing mental disease and in delivering phar-

macological treatments (Ecks and Basu 2009; Jain and Jadhav 2009; Patel et al. 2010). In some

rare cases, also motivated by cultural critiques of community psychiatry in India (Jain and

Jadhav 2008), this has led to cooperation programs such as Dava & Dua in Gujarat, involving

psychiatrists and ritual healing specialists (Government of Gujarat 2003; Basu 2009).

Surprisingly little has been written on the integration of ‘Indian Systems of Medicine’ and

Ayurveda, in particular, in the promotion of community mental health care in India. Although

Indian psychiatrists have had an interest in Ayurvedic concepts and the management of mental

illness from the late 1950s (Jain and Jadhav 2008; Sebastia 2009), this interest has rarely resulted

in the integration of Ayurveda into mental health programs. Most mental health projects, as well

as the NMHP and the different DMHPs, ignore the Ayurvedic discourse on mental health and

depression that we have described in the previous pages. While Ayurveda has been integrated

into general public health schemes in India (Brass 1972; Wujastyk 2008) and in other South

Asian countries such as Nepal (Cameron 2008) and Sri Lanka, Ayurveda has, apart from some

rare exceptions, not played a significant role in the public mental health care either in Kerala or

elsewhere in India.

In an article called ‘‘Mental Health Policy for Kerala State’’ (2000), the Kerala State Mental

Health Authority (KSMHA) proposed the integration of mental health into Ayurvedic training

and ‘‘to start full fledged psychiatric departments in all Ayurveda Colleges and psychiatric units

in all Ayurvedic District Hospitals with minimum five beds’’ (30). However, the KSMHA has

made no efforts to integrate Ayurvedic mental health care into mental health programs.

Likewise, the WHO report, ‘‘Integrated Primary Care for Mental Health in the Thiruvanantha-

puram District, Kerala State’’ (2008), although otherwise rather inclusive, excluded Ayurvedic

clinicians from contributing to mental health care in the state.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

The Ayurvedic engagement of biopsychiatric concepts such as depression, as well as research

on the efficacy of Ayurvedic herbs and procedures conducted at Ayurvedic research institutes

and colleges, predisposes Ayurveda as an important component in ‘‘culturally sensitive psychi-

atric theory and clinical services’’ (Jain and Jadhav 2008:561) in Kerala. Why not integrate

Ayurvedic practitioners into mental health programs and, in particular, community mental health

services, especially in Kerala where Ayurveda is popular enough (Halliburton 2009; Sebastia

2009)? Why not engage an Ayurvedic psychiatrist as part of the team of ‘community health

camps,’ which currently consist of psychiatrists, psychologists, and social workers? The

integration of Ayurveda into community health care would not only contribute to a greater avail-

ability and accessibility of mental health experts in the state but also to a diversity of different

forms of therapy, especially for common mental disorders, which would again improve

outcomes for these disorders (Halliburton 2004).

Many families who approach Ayurvedic hospitals and clinics for depression believe that Ayur-

vedic medications and procedures for mental illness are less invasive, have no side effects, and ‘‘fitthe Indian mind better than English medicine.’’ Although addressing therapeutic measures rather

than conceptualizations, the argument of fitting the Indian mind is related to another critique of

global mental health that it is based on a singular and culturally inappropriate model of mental

health. Where proponents of Global Mental Health call for ‘scaling up’ services for mental disor-

ders in low- and middle-income countries (Lancet Global Mental Health Group 2007; Patel et al.

2008), critics challenge the assumption ‘‘that Western frameworks can generate a universally valid

knowledge base’’ (Summerfield 2008:992). We agree with Summerfield and others that the differ-

ent versions of ICD and DSM ‘‘are shaped by contemporary notions about what constitutes a real

disorder, what counts as scientific evidence, and how research should be conducted. They are

Western cultural documents par excellence’’ (2008:992). We also agree with Chowdhury,

Chakraborty, and Weiss (2001) that cultural epidemiological studies are important and should

inform policies and with Jakubec, who argued for ‘‘rediscovering local truth’’ (2004:23).Beyond this critique, the data presented in this article suggest that the binary opposition of

biopsychiatric and local notions of mental distress needs to be revised, along with the question

of whether depression is universal or culture-bound (Kleinman and Good 1985; Kirmayer 2001;

Kirmayer and Jarvis 2006; Jadhav 2000; Raguram et al. 2001). Patients and caregivers adopt

the biopsychiatric concept of depression, buy antidepressants, use it as an ‘‘idiom of distress’’(Nichter 1981), and hybridize it with other local notions of mental illness. But also, using the

case of Ayurveda, we have shown in this article that ‘Indian Systems of Medicine’ appropriate

‘depression’ and integrate it into their own frameworks of knowledge. Thus, instead of arguing

that biopsychiatric categories are culturally inappropriate, the question must be how and why

these categories are being made appropriate, how they are adapted and transformed by various

stakeholders to fit local medical and religious contexts, how this impacts how the society per-

ceives and deals with people with mental illness, and how the latter experience their ailments.

The process of Ayurvedic clinicians and students adopting biopsychiatric categories cannot be

understood as simply a Western, culturally inappropriate model of depression being superim-

posed on them. Rather than being passive victims of the hegemony of biomedicine with respect

to defining mental illness, practitioners of Ayurvedic psychiatry display agency in creatively

appropriating ICD-categories and reinterpreting Ayurvedic scriptures and practices in the light

of biopsychiatric categories on the one hand, reframing ‘depression’ according to the local

context of Kerala on the other.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

CONCLUSION

The appropriation of global biopsychiatric disorders such as depression and their reframing

within Ayurvedic theory is related to a process of reinventing and institutionalizing Ayurvedic

psychiatry as a modern science. One key feature is the discarding of spirits and the focus on the

‘‘context-free’’ (Halliburton 2005) dos_a and biopsychiatric categories as scientific diagnoses.

Graha unmada, on the other hand, have either become irrelevant for diagnostics or are reinter-

preted as ‘psychotic features’ or as a ‘personality disorder.’ Thus, Ayurvedic psychiatrists

explain the ‘spiritual’ side of Ayurvedic concepts and practice in terms of the secular and physio-

logical explanations of Ayurveda and biopsychiatry. They strategically accentuate Ayurvedic

physiology to respond to biomedicine. This is facilitated, we argue, by the fact that the ‘‘diag-nostic liquidity’’ (Lakoff 2005:63) of the neurochemical conception of depression and the abol-

ition of etiology since the publication of the DSM-III is more compatible with Ayurvedic notions

of a fluent body (Langford 2002) and mind. These concepts are easier to equate with Ayurvedic

concepts of dos_ic imbalances and blockages of channels than was the former psychoanalytically

dominated model of psychiatry.

Correlations and translations of biopsychiatric concepts into Ayurvedic ones, and vice versa,

although often contested, are not only guided by the quest to present Ayurvedic psychiatry as

both an ancient and a modern science but also by efforts to participate in the mental health care

of Kerala, which is dominated by the biopsychiatric discourse. Therefore, Ayurvedic psychia-

trists neither mimic the biopsychiatric idiom nor do they merely cite biopsychiatric terms, as

Langford (1998) has observed. Their agency lies in the creative appropriation and reframing

of biopsychiatric concepts within Ayurvedic theory. Ayurvedic knowledge on mind, body, men-

tal health, and classifications of mental disorder are not replaced by biopsychiatric concepts but

rather confirmed by them. By integrating biospychiatric concepts such as depression within an

Ayurvedic theory of dos_a, gun

_a, mind and body, Ayurvedic psychiatrists not only make them

decisively Ayurvedic illnesses treatable with Ayurvedic therapies (Langford 2002:289) but also

transform and adopt them to local moral worlds.

We have limited our discussion to the processes of appropriating depression into the diagnos-

tic framework of Ayurvedic psychiatry. The issue of the therapeutic consequences of this pro-

cess in Ayurvedic practice, especially with regard to the commodification of Ayurvedic drugs

and treatment procedures, as well as to Ayurvedic practices of ‘psychotherapy’ (sattvavajaya)(Langford 2002), is an important area for further investigation. Moreover, we have focused

on how Ayurvedic practitioners use biopsychiatric categories in a fluid manner. Future publica-

tions will have to explore the perspectives and experiences of patients and their caretakers on

‘depression’ and the pragmatic use of different therapeutic services.

Another important topic for further investigation is the transformation of patients’ subjectiv-

ities facilitated by the biomedicalization and pharmaceuticalization of mental distress on the one

hand and by ‘‘imported interiority’’ (Langford 2002) on the other.

The appropriation of biopsychiatric concepts such as depression, within the context of

Ayurvedic theory and practice, could be the basis on which Ayurvedic psychiatry can and should

be integrated into mental health programs and, in particular, into community mental health care

in Kerala and even India. Addressing Global Mental Health debates, we agree with critics that

the concept of depression as historically and culturally constituted cannot be presumed in differ-

ent local realities. However, we attempted to push the debate between relativistic and universal


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

attitudes toward depression one step further. We suggest that future cross-cultural studies on

depression can gain a lot by leaving the question of whether depression is universal or culture-

specific aside, and instead, focusing on the multiple processes of appropriating, reframing, trans-

forming, or, in short, ‘‘glocalizing’’ (Robertson 1995) depression as a disorder within indigenous

medical knowledge and practice in a given context.

ACKNOWLEDGMENTS

We are grateful to the German Research Foundation (DFG) for funding the research on the

glocalization of depression in Kerala from 2009 to 2011, on which this article is based. We

would also like to thank Murphy Halliburton and two anonymous reviewers from MedicalAnthropology for their inspiring comments and suggestions.

NOTES

1. Excepting Dr. Tom Paul, who explicitly wished to be mentioned by his real name, all names of doctors are

pseudonyms.

2. Bhut vidya is the knowledge of bhuta. Bhuta is any existent ontological entity. Graha means a possessing entity as

well as a planet; an entity delineated by its ability to grasp or to hold (grh). The terms bhuta and graha are generally used

as equivalents (Smith 2006:471–486). Cikitsa means treatment.

3. Dos_a are both principles and substances governing the physiological functioning of the body and mind. Vata is the

moving, pitta the transforming, and kapha the stabilizing principle or substance. In some publications dos_a are glossed as

humors. For a discussion on dos_a as principles or substances, see Langford (2002) and Halliburton (2009). For better

readability, we use the transliterations ‘wind’ for vata, ‘bile’ for pitta, and ‘phlegm’ for kapha where it is appropriate,

although these translations are problematic (Langford 2002; Halliburton 2009).

4. The operational language since DSM-III, ‘‘an informatics language of codable symptoms and computerizable cri-

teria,’’ aims for matching specific diagnoses with specific drug treatments (Orr 2010:357). This matching of ‘‘universal’’

(Halliburton 2005) diagnoses with specific drugs along with randomized controlled trials of Ayurvedic formula, the fash-

ioning of therapeutic recipes into biotechnological health products and the standardization of active ingredients are parts

of the scientification or biomedicalization of Ayurveda (Bode 2006; Banerjee 2008; Halliburton 2011; cf. Sujatha 2011

for a critique of these innovations in traditional medicines in India).

REFERENCES

Applbaum, K.

2006 Educating for global mental health: The adoption of SSRIs in Japan. In Global Pharmaceuticals: Ethics,

Markets, Practices. A. Petryna, A. Lakoff, and A. Kleinman, eds. Pp. 85–110. Durham, NC, and London: Duke

University Press.

Banerjee, M.

2008 Ayurveda in modern India: Standardization and pharmaceuticalization. In Modern and Global Ayurveda:

Pluralism and Paradigms. D. Wujastyk and F. Smith, eds. Pp. 201–214. Albany, NY: State University of

New York Press.

Basu, H.

2009 Contested practices of control: Psychiatric and religious mental health care in India. Curare 32(1–2):

28–39.

Bhatt, R., S. K. Maheshwari, K. Rao, and R. Bakshi

2007 Mental health care pilots in Gujarat: Processes, outcomes and learning. Anmedabad, India: Indian Institute of

Management Ahmedabad.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

Bhugra, D. and A. Mastrogianni

2004 Globalization and mental disorders: Overview with relation to depression. British Journal of Psychiatry

184(1):10–20.

Bode, M.

2006 Taking traditional knowledge to the market: The commoditization of traditional medicine. Anthropology &

Medicine 13(3):225–236.

Brass, P.

1972 The politics of Ayurvedic education. In Education and Politics in India. L. H. Rudolph and D. I. Rudolph, eds.

Pp. 342–371. Delhi: Oxford University Press.

Cameron, M.

2008 Modern desires, knowledge control, and physician resistance: Regulating Ayurvedic medicine in Nepal. Asian

Medicine 4:86–112.

Chowdhury, A. N., A. K. Chakraborty, and M. G. Weiss

2001 Community mental health and concepts of mental illness in the Sunderban Delta of West Bengal, India.

Anthropology & Medicine 8(1):109–129.

Chua, J. L.

2009 The productivity of death: The social and political life of suicide in Kerala, South India. PhD thesis, Department

of Anthropology, Stanford University.

Clarke, A., L. Mamo, J. R. Fosket, J. R. Fishman, and J. K. Shim, eds.

2010 Biomedicalization: Technoscience, health, and illness in the US. Durham, NC, and London: Duke University

Press.

Desjarlais, R., L. Eisenberg, B. Good, and A. Kleinman

1995 World Mental Health: Problems and Priorities in Low-Income Countries. New York: Oxford University

Press.

Ecks, S.

2005 Pharmaceutical citizenship. Antidepressant marketing and the promise of demarginalization in India.


Ecks, S. and S. Basu

2009 The unlicensed lives of antidepressants in India. Generic drugs, unqualified practitioners, and floating prescrip-

tions. Transcultural Psychiatry 46(1):86–106.

Giguere, N.

2009 Dos_a, Satvabalam, genes, and Puja: A God for everything. An ethnographic study of a government Ayurvedic

mental hospital. In Restoring Mental Health in India: Pluralistic Therapies and Concepts. B. Sebastia, ed.

Pp. 48–70. New Delhi: Oxford University Press.

Good, B. J.

1992 Culture and psychopathology: Directions for psychiatric anthropology. In New Directions in Psychological

Anthropology. T. Schwartz, G. M. White, and C. A. Lutz, eds. Pp. 181–205. Cambridge, UK: Cambridge

University Press.

Government of Gujarat

2003 Priorities for Mental Health Sector Development in Gujarat (The Mission Report 2003). Gandhinagar, India:

Department of Health and Family Welfare, Government of Gujarat.

Halliburton, M.

1998 Suicide. A paradox of development in Kerala. Economic and Political Weekly 33(36=37):2341–

2345.

———.

2005 ‘‘Just some spirits’’: The erosion of spirit possession and the rise of ‘‘tension’’ in South India. Medical

Anthropology 24(2):111–144.

———.

2009 Mudpacks & Prozac: Experiencing Ayurvedic, Biomedical & Religious Healing. Walnut Creek, CA: Left Coast

Press.

———.

2011 Resistance or inaction: Protecting Ayurvedic medical knowledge and problems of agency. American

Ethnologist 38(1):86–101.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

Healy, D.

2004 Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression.

New York: New York University Press.

Horwitz, A. and J. Wakefield

2007 The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Oxford, UK:

Oxford University Press.

Jadhav, S.

2000 The cultural construction of Western depression. In Anthropological Approaches to Psychological Medicine:

Crossing Bridges. V. Skultans, and J. Cox, eds. Pp. 41–65. London and Philadelphia, PA: Jessica Kinsley

Publishers.

Jain, S. and S. Jadhav

2008 A cultural critique of community psychiatry in India. International Journal of Health Services 38(3):561–584.

———.

2009 Pills that swallow policy: Clinical ethnography of a community mental health program in Northern India.

Transcultural Psychiatry 46(1):60–85.

Jakubec, S.

2004 The ‘‘world mental health’’ framework: Dominant discourses in mental health and international development.

Canadian Journal of Community Mental Health 23(2):23–28.

Jefferey, R.

1988 The Politics of Health in India. Comparative Studies of Health Systems and Medical Care. Berkeley: University

of California Press.

Kerala State Mental Health Authority

2000 Mental Health Policy for Kerala State. http://www.ksmha.org.

Kirmayer, L. J.

1997 Somatization in social and cultural perspective: From research to clinical strategies. Japanese Journal of

Psychosomatic Medicine 37(6):311–319.

———.

2001 Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treat-

ment. Journal of Clinical Psychiatry 62(suppl. 13):22–30.

———.

2002 Psychopharmacology in a globalizing world: the use of antidepressants in Japan. Transcultural Psychiatry

39(3):295–322.

Kirmayer, L. J. and G. E. Jarvis

2006 Depression across cultures. In Textbook of Mood Disorders. D. Stein, A. Schatzberg, and D. Kupfer, eds.

Pp. 699–715. Washington, DC: American Psychiatric Press.

Kitanaka, J.

2006 Society in distress: The psychiatric production of depression in contemporary Japan. PhD thesis, Department of

Anthropology, McGill University.

Kleinman, A. and B. Good

1985 Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder.

Berkeley: University of California Press.

Kohrt, B. A.

2005 ‘‘Somatization’’ and ‘‘comorbidity’’: A study of Jhum-Jhum and depression in rural Nepal. Ethos 33(1):

125–147.

Krishnamurthy, N.

1964 Counselling as we find in the Gita. Transactions. All India Institute of Mental Health, Bangalore 4:42–49.

Kuppuswamy, B.

1959 Bhagavad-Gita and mental health. Transactions. All India Institute of Mental Health, Bangalore 2:

107–111.

Lakoff, A.

2005 Diagnostic liquidity: Mental illness and the global trade in DNA. Theory and Society 34(1):63–92.

Lancet Global Mental Health Group

2007 Scale up services for mental disorders: A call for action. The Lancet 370(9594):1241–1252.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

Langford, J.

1998 Ayurvedic psychotherapy: Transposed signs, parodied selves. Political and Legal Anthropology Review

21(1):84–98.

———.

2002 Fluent Bodies: Ayurvedic Remedies for Postcolonial Imbalances. Durham, NC, and London: Duke University

Press.

Leslie, C.

1992 Interpretation of illness: Syncretism in modern Ayurveda. In Paths to Asian Medical Knowledge. C. Leslie and

A. Young, eds. Pp. 177–208. Berkeley: University of California Press.

Meulenbeld, G. J.

2001 Reflections on basic concepts of Indian pharmacology. In Studies on Indian Medical History. G. J. Meulenbeld

and D. Wustastyk, eds. Pp. 1–16. Delhi: Motilal Banarsidass.

———.

2008 The woes of Ojas in the modern world. In Modern and Global Ayurveda: Pluralisms and Paradigms.

D. Wujastyk and F. Smith, eds. Pp. 157–176. Albany: SUNY Press.

Murray, C. and A. Lopez

1996 Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries,

and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard School of Public Health.

Naraindas, H.

2006 On spineless babies and folic acid: Evidence and efficacy in biomedicine and Ayurvedic medicine. Social

Science & Medicine 62(11):2658–2669.

Nichter, M.

1981 Idioms of distress: Alternatives in the expression of psychosocial distress. A case study from South India.

Culture, Medicine and Psychiatry 5(4):379–408.

Nichter, M. and C. Nordstrom

1989 A question of medicine answering. Health commodification and the social relations of healing in Sri Lanka.

Culture, Medicine, and Psychiatry 13(4):367–390.

Nisula, T.

2006 In the presence of biomedicine: Ayurveda, medical integration and health seeking in Mysore, South India.


Nizamie, S. H. and P. Desarkar

2005 Community psychiatry in India: Future perspective. Indian Journal of Social Psychiatry 21(2–4):93–102.

Obeyesekere, G.

1985 Depression, Buddhism, and the work of culture in Sri Lanka. In Culture and Depression: Studies in the

Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. A. Kleinman and B. Good, eds.

Pp. 134–152. Berkeley: University of California Press.

Patel, V., P. Garrison, J. Jesus Mari, H. Minas, M. Prince, and S. Saxena

2008 The Lancet’s series on global mental health: One year on. The Lancet 372(9646):1354–1357.

Patel, V. and A. Sumathipala

2006 Psychological approaches to somatization in developing countries. Advances in Psychiatric Treatment 12:

54–62.

Patel, V. and G. Thornicroft

2009 Packages of care for mental, neurological, and substance use disorders in low- and middle-income countries.

PloSMedicine 6(10). http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000159.

Raguram, R., M. G. Weiss, S. M. Channabasavanna, and G. M. Devins

1996 Stigma, depression, and somatization in South India. American Journal of Psychiatry 153(8):1043–1049.

Raguram, R., M. G. Weiss, H. Keval, and S. M. Channabasavanna

2001 Cultural dimensions of clinical depression in Bangalore, India. Anthropology & Medicine 8(1):31–46.

Robertson, R.

1995 Glocalization: Time-space and homogeneity-heterogeneity. In Global Modernities. M. Featherstone, S. Lash,

and R. Robertson, eds. Pp. 25–44. London: Sage.

Rose, N.

2003 Neurochemical selves. Society 41(1):46–59.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

Sebastia, B.

2009 Introduction: Restoring mental health. In Restoring Mental Health in India: Pluralistic Therapies and Concepts.

B. Sebastia, ed. Pp. 1–24. New Delhi: Oxford University Press.

Shaik Anwar, K. S.

2004 A study on Kaphonmada in relation with depressive disorders. MD thesis, Department of Kayachikitsa,

Vaidyarathnam P. S. Varier Ayurveda College.

Smith, F. M.

2006 The Self Possessed: Deity and Possession in South Asian Literature and Civilization. New York: Columbia

University Press.

Storck, M., T. Csordas, and M. Strauss

2000 Depressive illness and Navajo healing. Medical Anthropology Quarterly 14(4):571–597.

Sujatha, V.

2011 Innovations within and between traditions: Dilemma of traditional medicine in contemporary India. Science,

Technology and Society 16:191–213.

Summerfield, D.

2008 How scientifically valid is the knowledge base of global mental health? British Medical Journal

338(7651):992–994.

Sundaran, K.

1993 Treatment of mental diseases in Ayurveda. Unpublished translation from Malayalam. Kottakkal, India: Arya

Vaidya Sala.

Tarabout, G.

1999 ‘Psycho-religious therapy’ in Kerala as a form of interaction between local traditions and (perceived) scientific

discourse. In Managing Distress: Possession and Therapeutic Cults in South Asia. M. Carrin, ed. Pp. 133–154.

New Delhi: Manohari.

Weiss, M. G.

2010 In Madness (Unmada) In Brill’s Encyclopedia of Hinduism. Sacred Texts, Ritual Traditions, Arts, Concepts.

K. Jacobsen, H. Basu, A. Malinar, and V. Narayanan, eds. Pp. 798–805. Boston, MA and Leiden: Brill.

Weiss, M. G., R. Raguram, and S. M. Channabasavanna

1995 Cultural dimensions of psychiatric diagnosis: A comparison of DSM-III-R and illness explanatory models in

South India. British Journal of Psychiatry 166(3):353–359.

World Health Organization

2008 Integrating Mental Health into Primary Care: A Global Perspective. Geneva: World Health Organization.

———.

2009 Improving Health Systems and Services for Mental Health. Geneva: World Health Organization.

Wujastyk, D.

2003 Indian medical thought on the eve of colonialism. International Institute for Asian Studies Newsletter 31:21.

———.

2008 The evolution of Indian Government policy on Ayurveda in the twentieth century. In Modern and Global

Ayurveda: Pluralism and Paradigms. D. Wujastyk and F. Smith, eds. Pp. 43–76. Albany: SUNY Press.

Wujastyk, D. and F. Smith, eds.

2008 Modern and Global Ayurveda: Pluralisms and Paradigms. Albany: SUNY Press.

Zimmermann, F.

1989 Le Discours des Remedes au Pays des Epices: Enquete sur la Medicine Hindoue. Paris: Payot.


Dow

nloa

ded

by [

Bay

eris

che

Staa

tsbi

blio

thek

] at

00:

34 1

1 Ju

ly 2

013

Lang Jansen Appropriating Depression

Documents

Transcript of Lang Jansen Appropriating Depression