This the second instalment of my engagement with an account of a new, two-question screening test for depression. The first part of my critique was in the previous post.The one aspect of my critique that I didn’t deal with last time was the issue of pleasure. The screening test asks the following question:
2. During the last month, have you often been bothered by having little interest or pleasure in doing things?
which follows the ICD10 diagnostic criteria of the depressive episode:
(2) loss of interest or pleasure in activities that are normally pleasurable.
I have already commented on the shift from the ICD10, which stresses change, to the level of interest. I commented that ‘little interest’ should not be asked about and, indeed, pathologised. But what about pleasure? Well, I have even more problems with it.
I would like to tell you two stories. One is about my late father. He was a design engineer, indeed, he designed parts of many buildings, factories, prisons, schools (inter alia) in the city and region where we lived. He was extremely proud of his work and whenever he was passing any of these buildings with anyone, he would always say: “I designed it.”, regardless of how many times the person he was addressing had already heard it. His work was him and he was his work. To a considerable extent, he never stopped working. And when I stop to think about him, I find it very difficult to say what kind of things he did for pleasure.
Yes, he read plenty of books on WWII, but I think it was much more to do with making sense of what happened to him during the war than anything to do with pleasure. He never went to the cinema (unless my mother ordered him to take me to a movie), he watched TV, but it was more a way to wind down (there were periods when his work was stressful in the extreme), we went on holidays, because ‘one did go on holidays’. No, he didn’t have much social life, he always said that his colourful young years were quite enough.
The second story is about a brief exchange at a greengrocer’s kiosk. I was buying a watermelon (I love watermelon) in a Polish village where I used to spend summer holidays and as I was putting it into a bag, a man standing next to me said something like:
I’ve never had this in my mouth.
The tone of what he said was quite matter-of-fact. I’m not sure why, but he was simply stating that he had never tried watermelon; perhaps there was a hint of repproach that I had. Also, I wasn’t sure what to do about it – even if I did consider cutting a slice and offer him (and I didn’t particularly), I had no knife, I was leaving the counter, he was still in the queue. So I mumbled something about watermelon being quite cheap.
But this exchange got me thinking. Why didn’t he buy the fruit? Because of the imports from Hungary, watermelon in Poland is cheap (and delicious – nothing like the strange unripe stuff you can buy in British supermarkets). Why wouldn’t he buy himself a quarter and try? I still remember when kiwi fruit appeared in Poland after the collapse of communism. It was very expensive at first, I still bought it, because I was curious how it tasted (I still remember the disappointment – I expected ambrosia, I got a kiwi). So why? Well, I don’t know, but I suspect it’s to do with masculinity and the rejection of frivolity. Pleasure of eating watermelon simply didn’t arise for this man.
And here we come to the main point of this blog. These two stories are about two very different men. For one pleasure didn’t really feature much in his life, the other could not imagine having a little treat of watermelon. And so, you must wonder what my father and the other man would say to a question like the one above (my father would have been in his late 80s, so he would qualify to be asked). I suspect his eyes would glaze over and he would walk away, saying that he doesn’t have time for idiots (and he didn’t suffer fools gladly – he really didn’t). I think the question didn’t really arise.
Certainly for my father, this ‘perpetual euphoria’, the ‘duty to be happy’ (It’s a title of a book) would just be something he wouldn’t understand. His satisfaction (I doubt it was pleasure) was to bring his salary home, put on the table and let my mother and me admire him, which we duly did. I actually do remember my father coming back home with a big wad of notes (salaries were paid in cash at the time), as he got a bonus. He was the man!
Whenever I tell this story, I am reminded of an interview I carried out for my book on men and depression. Here is an exchange I had with an informant:
DE: I would harness, harness myself to life again, which was such a positive [laughs] stimulus in life for me.
DG: you miss the harness?
DE: I do. Nothing pulls, I don’t know which way, which way to go, and one always went straight, one used to go straight, and now one goes sideways, one leans out too much, doesn’t know what to do with oneself. This is the worst, not to know. You come home and you don’t know, neither to go out, nor to stay, nor to lie down, sleep, nor to help out with something. You don’t know how to organise your life. Which is the worst for me in this depression, this is the worst. I would prefer being pressed more, than be so free.
The speaker is not interested in enjoyment, in happiness or even lack of sadness. His is interested in a yoke, in a duty one has to cope with. He wants a struggle, something that grinds him down while he manages to cope and overcome it. The imagery of the harness is the imagery of a working horse that has to pull a wagon which is so heavy that its back could break. But the wagon moves off and the horse wins. He wants a life in which he can win against the odds.
I have no idea how you can ask this man about pleasure. The moment you look at life through his eyes, you see that pleasure, again, doesn’t arise. And it hardly makes sense to impose ‘our’ frame of reference onto his experience.
And so, what does the questionnaire measure? Again, I don’t know. I suspect, however, that whatever it measures, has little to do with what is important and relevant for the men I told you about. But, importantly, it does correlate.…