Medicine has several lives; it gains a new life in each language and creates new cultural forms in each temporality. In 1990s Iran, a cultural shift took place in public articulations of psychological well-being, manifest in the evolution of a psychiatric discourse in the media and a rise in psychiatric talk among people. By the end of the 1990s, a Persian psychiatric vernacular had emerged in society: afsordegi (depression), depreshen, dep zadan (becoming depressed), toromā (trauma), esteress (stress), bish-fa’āli (hyperactivity in children), and the Persianized catchall term for antidepressants, Prozāk.1 This shift toward a clinical and psychiatric discourse for talking about psychological distress was indeed part of a broader historical and cultural change. Traditionally, one discussed psychological and psychiatric pathologies primarily in a concealed, private, poetic, or religious language. After all, in Persian poetics, Sufi traditions, and the Shi’ite ethos of conduct, stoicism had an elevated status. Far from medicalized, melancholic gravitas signaled depth of character achieved through spiritual transcendence, unrequited love, and unshaken faith.2 Within the medical establishment too, psychiatry had historically been seen as the unwanted child of medicine, its image marred by its allegedly less scientific foundations and the close proximity many of its key figures had to the world of letters and the humanities—if not the stigma of madness itself. Throughout the twentieth century, Islamist and Marxist ideologies too had further regarded psychiatry and particularly its psychoanalytical legacies as Western constructs that contradicted the ethos and priorities of the revolution.3 But this was all to change.
In the late 1980s, a psychiatric discourse began to enter the media; a space emerged where psychiatrists and psychologists began educating the public about mental health. They introduced signs and symptoms of mood and anxiety disorders, as well as clinical and diagnostic frames with which people could understand their psychological experiences. This was a new opportunity for psychiatry, as a discipline, to be claimed in a specifically Iranian context. Psychiatric talk was now public and explicit.
When we find ourselves embracing a particular form of knowledge—in this case, psychiatry—it is tempting to assume that certain forms of illness must have become either more common or more efficiently diagnosed than before. Real life is more complex. The narratives and languages we choose have as much, if not more, to say about the world we have lived in than about what we are telling. Our choices—of languages, of concepts, of frameworks, of the bodies of knowledge we draw upon—are truly ours only insofar as we choose from what is culturally, scientifically, psychologically, and historically legitimate, accessible, and available to us. The internalization of new articulations necessitates, and reflects, the internalization of mindsets that have made that particular language intelligible and instrumental for us. In doing so, it reveals historical, cultural, and epistemological possibilities and impossibilities that have made a particular form of knowledge fit for a particular people at a particular time and place. This book is meant to describe some of those possibilities and impossibilities that might easily be overlooked by purely biomedical explanations.
Indeed, recent developments of medical disciplines need to be situated in several historical contexts, including that of the Iran-Iraq War (1980–1988). Shortly after the 1979 Revolution, Iraq invaded Iran and ignited a destructive eight-year war that resulted in a large number of casualties and adverse health conditions, as elaborated in numerous studies conducted by Iranian clinicians and researchers who have documented the physical and mental health impact of the war among veterans and civilians alike.4 The postwar years were also marred by economic sanctions imposed by Western governments, many of which continue to this day with health-care-related implications. Yet the Iran-Iraq War (officially, in Iran, the Sacred Defense) also engendered new societal norms and solidarity; it mobilized, through educational and media campaigns, the Shi’ite ethos of endurance and sacrifice for justice.
For clinicians and policymakers, wartime concerns with post-traumatic stress disorder (PTSD) and anxiety disorders were replaced, in the 1990s, with concerns about depression and dysphoria. A discourse of mental health (salāmat-e ravāni) began to emerge, with the primary focus on raising awareness about and destigmatizing psychological disorders. Gradually, growing numbers of mental health talk shows and newspaper columns on psychiatric topics introduced a new clinical vernacular that gave people a way to discuss the very real pain that lingered from the war. This clinical language was both validated and welcomed by doctors as well as policymakers because and insofar as it fit several other paradigms in the late 1980s. The biomedical, authoritative, and symptom-centered language of psychiatry indicated that the malaise so many were experiencing resided in the purview of medicine. In the absence of an alternative public discourse, psychiatry and disorder provided society with a legitimate language to channel psychological and social experiences after the war. However, while the war is an important historical context, it does not solely explain the growing popularity of psychiatric discourses among people.
As psychiatric terminologies and diagnoses moved outward from the privacy of clinical encounters, a shift began to appear in language. People began to speak more publicly and commonly of their prescriptions for ghors-e a’sāb (nerve pills)5 and of depreshen, jokingly, as an “epidemic,” a “crisis,” or a “national trait.” Everyone allegedly knew someone who was depress. Depreshen became street slang, and gradually it became less surprising to hear individuals talk about depression or call themselves depress, or afsordeh. Media, art, literature, and blogs adopted an explicitly medicalizing discourse of afsordegi/depreshen and statistical reports on mental health began circulating in the media. By the early 2000s, websites and blogs dedicated to mental health flourished among Iran’s growing educated and urban population.
This, of course, was in part an outcome of media and educational campaigns for destigmatizing mental illness (particularly mood disorders); but a certain kind of receptivity and readiness for this language ought to have been in place among people and practitioners alike. A decade after the end of the war, reports emerged of a surge in antidepressant (and later Ritalin) consumption. Doctors both welcome this as a step forward in raising awareness (and better illness detection) and speculate about possible overmedication, but explain that medication is usually the first line of intervention for a number of practical reasons: the lack of a well-funded mental health care infrastructure, the arbitrary distribution of patients among specialties, the lack of patients’ compliance with psychotherapy, and a culture of quick fixes, as well as what they perceive as a clash of tradition and modernity. But they still advocate medication and insist that it provides relief, destigmatizes psychological problems, eliminates guilt, and projects modernist and educated attitudes. Above all, it provides hope.
1. This new vernacular is indeed situated in a rich vocabulary of affect in Persian literature. Such renditions can also be traced in medical scripture such as the Canon of Medicine, the chef d’oeuvre of the eleventh-century Persian physician and philosopher Avicenna. In the third volume, under the section “Ailments of the Mind and Spirit,” he devotes a chapter to love melancholy, diagnosed by detecting an increase in the patient’s pulse when the name of the beloved is mentioned. In his diagnostic criteria, sorrow (maluli) is not a pathological symptom, but an inevitable state of infatuation (Avicenna 1989). Robert Burton, in his famous text The Anatomy of Melancholy (circa 1600), refers to Avicenna’s love melancholy frequently under the category “head melancholies” (Burton 1927).
2. For more on anthropological investigations of Iranian affective structures, see Behzadi 1994; Beeman 1988, 1985, and 2001.
3. As was the case in other revolutions globally, including the rise of Bolshevism in Russia. On the uneven global distribution of psychiatry, see Derrida 1998.
4. See S. M. Razavi et al. 2014; Ebadi et al. 2009; Ebadi et al. 2014; Roshan et al. 2013; Khateri et al. 2003; Falahati et al. 2010; Khateri and Bajoghli 2015; Ghanei et al. 2005; Hashemian et al. 2006; Birch et al. 2014; and Karami et al. 2013. With the exception of a few studies that evaluated children (for example, S. H. Razavi et al. 2012; Taghva et al. 2014; and Yousefi and Sharif 2010), most epidemiological studies of PTSD and other psychiatric conditions in the aftermath of the Iran-Iraq War have primarily focused on adults. Among qualitative studies of the psychological impact of city bombardments on children, see Rahimi 2010 in Negin-e Iran: The Journal of Research on the Sacred Defense. For a detailed report on the health-related consequences of the Iran-Iraq War, see the Health Impact Assessment Report compiled by Medact (2014): http://www.medact.org/wp-content/uploads/2014/06/Health-Impact-Assessment-Word-Website-+-MB.pdf.
5. Note that practitioners frequently warn of growing self-prescription. For example, see “Self-medicated and Depressed” in the weekly newspaper Sepid (15/11/1393—4/02/2015): http://www.salamatiran.com/NSite/FullStory/?Id=76308&type=3.