Political commentators and activists sometimes seem to imagine that psychiatric diagnoses are uncontroversial. They write as though depression, for example, were as firmly-established and scientifically evidenced as, say, diabetes. This has the effect of reifying psychiatric diagnoses – of making them appear more real, more concrete, more legitimate. It also works to undermine critiques: of diagnosis, and of psychiatry more generally. We see this from commentators across the political spectrum. However, it is especially disappointing and unhelpful when it comes from the Left.

For example, a blog on the influential Novara Media site acknowledges that “mental health diagnoses are capitalist constructs” and explains how “diagnosis is shaped by systems of power”. Paradoxically, the same blog then encourages self-identification with psychiatric diagnoses. The political consequences of individuals choosing to actively identify with capitalist constructs are not considered.

Despite this contradiction, at least this blog explains how psychiatric diagnoses reproduce capitalist assumptions and power relations. By comparison, other blogs on Novara only avoid similar contradictions by invoking psychiatric diagnoses almost entirely uncritically. These include a blog purporting to explain depression that was published in memory of Mark Fisher (author of the influential book ‘Capitalist Realism’, who struggled with low mood himself). Another blog begins by stating that ‘Depression is political’, yet entirely fails to consider the political effects of conceptualising misery as a mental illness – in this instance, as depression.

A small handful of Novara blogs do contain some critical analysis of diagnosis (e.g. this piece about treatment guidelines, and this about mental health and the climate crisis). But their criticisms are muted, relatively brief, and always diluted by the uncritical use of psychiatric concepts such as ‘symptoms’ elsewhere in the piece.

Instead, using depression as an example, this blog will set out a consistent critique of psychiatric diagnosis. The observation, above, that mental health diagnoses are capitalist constructs provides a good starting point. What does this mean?

Depression is a Capitalist Construct

Saying that depression is a construct means three things. First, that depression is an abstract concept. In everyday life, there are many well-known abstract concepts. Examples include plants and animals; genders, races and social classes; marriages and nation-states.

Second, it means that depression has no physical substance of its own. Actual, living animals and plants are physical things, but the abstract concepts animal and plant are not. They were invented by humans, who might have chosen to conceptualise things differently. The South American novelist, Jorge Luis Borges, once proposed a fictional classification of animals that included: (1) belonging to the Emperor (2) embalmed (3) trained (4) suckling pigs (5) mermaids (6) fabled ones, and so on.

And third, like all constructs depression only exists thanks to a culturally and historically specific collective agreement. In the 1700’s in this country, both phlogiston and witches were collectively agreed to exist. Today, no-one believes in phlogiston, and the construct witch has changed greatly. And while in the 1700s some people were afflicted by a condition called melancholy or melancholia, there are many significant differences between this and the modern concept of depression.

Understanding that depression is a construct helps us approach it critically. It may be a fact that our society contains many profoundly miserable people. But the claim that these people have a mental illness called depression is not a fact: it is an interpretation, based on a construct. To further understand that depression is a capitalist construct simply means recognising how it has been shaped by capitalist imperatives. Two examples will suffice.

The first is by Mad in America founder, Robert Whittaker. He describes how, in the first part of the 20^th century, fewer than one in a thousand people each year in the USA reported experiencing episodes of depression, and these typically resolved spontaneously. A much smaller number were described as having clinical or chronic, long-term depression.

This began to change in 1980 when DSMIII removed the distinction between clinical and episodic depression. This change both created what was effectively a new disorder, and significantly expanded the potential market for drug treatments. In the years that followed:

“Pharmaceutical companies gave money to the APA to develop its PR machinery in the early Eighties, and then, in 1988, they provided funds to support the ‘Depression Awareness, Recognition and Treatment’ (DART) program, that was designed to sell the disease model to the public.”

In particular, people were encouraged to see their misery as a symptom caused by a brain chemical imbalance (more on this below). 1988 also saw the release of Prozac: the first of a new class of drugs called selective serotonin reuptake inhibitors (SSRI’s) that were often said to remedy chemical imbalances. The novel drug quickly found its newly-expanded market and by 1998 generated $2.8billion annual profit for manufacturer Eli Lilly.

Second, when DSM5 was published in 2013 the ‘bereavement exclusion’ had been removed from the diagnostic criteria for depression. Astonishingly, grieving for more than two weeks following the death of a loved one was now a potential symptom of mental illness. This change made many more people eligible for diagnosis, so increasing the market for drug treatment.

These examples show that when activists talk uncritically about depression, they breathe life into a construct thoroughly shaped by capitalist imperatives. Once activists interpret misery as an illness called depression, they are also more likely to agree that medically-trained specialists should manage it, that low mood is a symptom, that its cause lies within the brain or body, that the default treatment should be psychiatric drugs, and so on.

This discussion already suggests that a consistent critique of psychiatric diagnosis is relevant to activists. But there are three current issues making critique even more relevant. First, voluntary self-identification with psychiatric diagnoses is increasingly common, and sometimes described as subversive political activity: these claims surely require scrutiny. Second, the Labour government intends to reduce financial support for disability and incapacity claimants, the largest proportion of whom have mental health diagnoses. Activists who intend to oppose these cuts need to be clear about what diagnosis does, where it comes from, what its implications are etc.

And third, in recent years there has been an attempt to politically-reposition psychiatric diagnosis. Reflecting on responses to her work, critical psychiatrist Joanna Moncrieff (Chemically Imbalanced: The Making and Unmaking of the Serotonin Myth‘ 2025, p.188) said:

“The politics of mental health has gone through a curious metamorphosis in recent decades. People on the Left used to be the biggest critics of Big Pharma .. Now that job has fallen to [right-wing TV host, Tucker] Carlson. The Left used to be concerned that the medicalisation of mental health problems obscured the social and political causes of discontent .. Now, much of it is pushing medical diagnoses and anti-depressants”

In contrast, this analysis will show how critiquing diagnosis from a Left perspective is not just possible: it is essential.

A Consistent Critique of Diagnosis

Before proceeding, it’s important to be clear what a consistent critique of the diagnosis of depression involves. It means questioning the psychiatric view that depression is the effect of a brain disease, defect or dysfunction. It means being sceptical of the psychiatric belief that depression is, effectively, a medical illness. And, finally, it means thinking slightly differently about notions of ‘treatment’ or ‘cure’.

It’s equally important to be clear about what is not being questioned. There is no question that some people have awful experiences of enduring misery, worry and despair. There is no question that they sometimes experience such severe and prolonged anguish that they are wholly debilitated. When people have these terrible experiences, they cannot end them by sheer effort of will. They can’t simply try harder, pull themselves together, be rational, and so on. Their suffering is real, painful, and beyond their capacity to prevent. It is certainly not ‘all in their minds’.

Severe distress of the kind that psychiatry calls mental illness is the product of toxic experiences and adverse circumstances. The unequally distributed and adverse effects of power impress themselves forcibly upon us, body and mind. We absorb them as ‘sneering inner voices’ (as Mark Fisher put it), as overwhelming feelings, as timeless depths of numbness and apathy, and as mysterious compulsions beyond our control. They often produce unhelpful beliefs that can become so thoroughly engrained they appear, to us, as simply true.

In such ways the effects of power permeate the very fabric of our being. Because they become so intimately part of us, they simply cannot be wished away. Those of us so afflicted can no more ‘forget’ to continually doubt ourselves than we can forget how to swim. We cannot change hostile circumstances, nor undo their damaging effects, by using willpower, developing mindfulness, cultivating resilience and so on. These practices – staples of the lucrative self-help industry – may bring relief to some. But their effects are hard won, rarely maintained, and not available to all.

If people in the throes of distress could actually be more rational, more composed, less emotionally fragile, they surely would: after all, it would be in their own best interest. So when mixtures of toxic feelings (misery, dread, anger self-loathing, shame, despair) engulf people, it’s not a personal failing. Whether a slow falling apart, a persistent crushing or a sudden collapse, distress is not something people choose or invite. It happens to them, despite their best efforts, and regardless of what they can do.

For those mired in distress, its physical character can be as prominent as its psychological aspects. Profound misery can include immense fatigue, appetite and weight changes and unusual sleep patterns, as well as persistent low mood. But this shows only that misery is like other strong emotional states: it has both mental and physical dimensions. It does not show that these people have developed an illness called depression. On the one hand, there is no good scientific evidence for the existence of such an illness. On the other, it is not politically helpful to imagine that there is.

Questioning the Science of Depression

Since psychiatry conceives of depression as a discrete illness, it should co-occur with other psychiatric diagnoses only at chance levels. However, actual rates of co-occurrence are significantly higher. A global survey found that over 45% of people given a major depressive disorder diagnosis had also received one or more anxiety disorder diagnoses. Diagnoses of depression also overlap significantly with other diagnoses, including schizophrenia.

Psychiatry interprets these findings medically, as co-morbidity: one illness making another more likely. Since depression is an abstract capitalist construct, not a physical entity, this seems unlikely. Another interpretation is that the experiences psychiatry calls symptoms – of depression, anxiety disorder or whatever – are in fact experiential reactions to toxic circumstances, and as such do not align neatly with psychiatric diagnostic categories.

Nevertheless, psychiatry holds that depression is a discrete illness caused by a vulnerability such as a brain defect, impairment or disease.  According to psychiatry, not everyone has such a vulnerability which explains why not everyone subjected to a stressor such as poverty (a well-established cause of the experiences associated with a depression diagnosis), gets ill. Only some people in poverty experience distress, because those who do were already vulnerable. This is the ‘vulnerability-stress’ hypothesis.

Probably the best-known vulnerability is the claim that some people have a ‘brain chemical imbalance’. With regard to depression the brain chemical usually implicated is serotonin. Amongst other things, serotonin seems to be somehow linked to mood (the primary effect of the drug MDMA or ecstasy is to release serotonin). So according to this serotonin hypothesis only some people living in poverty become depressed, because only some people have imbalanced serotonin systems.

In other words, the ultimate cause of the misery that psychiatry calls depression is not poverty wages, run-down housing, isolated estates, abusive relationships, intrusive neighbours, bullying managers, bullshit jobs, inadequate benefits, threatening environments, aimless lives or hopeless futures. The ultimate cause of this misery is faulty biology: an explanation that medicalises reactions to poverty at the same time as it de-politicises them.

In a 2022 systematic review, psychiatrist Joanna Moncrieff and her colleagues demonstrated beyond reasonable doubt that there is no solid evidence for the serotonin hypothesis. However, the response from psychiatry was mixed. One research group vehemently rejected this conclusion and tried hard to demonstrate flaws in the analysis. Another team of researchers published a tiny (n=17) study supposedly showing support for the serotonin hypothesis. Simultaneously, many other psychiatrists simply accepted this conclusion, some elements of which were in fact already apparent. However, some psychiatrists have gone even further and claimed that no-one with relevant expertise has ever said that depression is caused by a serotonin system imbalance! This astonishing claim is flatly contradicted by decades of pharmaceutical advertising and hundreds of psychiatric research papers and textbooks, all demonstrating that such authoritative claims were commonplace.

This helps explain why the SSRIs commonly prescribed for people with depression diagnoses have such variable effects that, in randomised trials, they do not always perform better than placebo. These drugs are not correcting an imbalance of the serotonin system. They are simply creating an artificially elevated mood by making serotonin levels in the brain increase.

Serotonin is involved in very many brain functions. Even though it is one of the most researched neurotransmitters we know relatively little about its effects. For reasons that are largely unknown, and by pathways that are unclear, artificially increasing serotonin this way has variable effects. For some people, it seems to make very little difference; for others, it can lead to agitation and anxiety; but for a proportion the end result is slightly elevated mood.

For those in the depths of misery who need nothing so much as respite from their anguish, this elevated mood can be helpful. But for others, whose circumstances are more pressing, it can actually be unhelpful. The artificial raised mood that SSRIs induce can prevent productive worrying, make it difficult to focus on problems, and reduce motivation to change difficult situations. So whether SSRIs are helpful depends in part upon the fit between the raised mood they artificially create, and the particular needs and circumstances of the person.

In any case, there is no solid evidence for the serotonin hypothesis. What is more, we can draw a similar conclusion in relation to all of the supposed biological vulnerabilities and genetic predispositions said to cause the experiences that psychiatry calls depression: none are supported by consistent evidence.

We can take this argument considerably further, since the diagnosis of depression is not unusual in this regard. There is in fact no consistent evidence for any biological or genetic vulnerability in relation to any of the functional psychiatric diagnoses (schizophrenia, bipolar disorder, depression, anxiety disorder, ADHD, eating disorders, personality disorders and so on). There are no ‘biomarkers’ for any of these so-called mental illnesses, to use the psychiatric jargon.

This failure to find any biomarkers is embarrassing for a psychiatry which, over the last few decades, has argued strongly that the primary causes of distress are biological. Consequently, advocates of psychiatry typically either avoid mentioning the absence of biomarkers, or use rhetorical tricks to obscure or play it down. Occasionally, though, it gets openly admitted. In the 2013 press release launching DSM5 David Kupfer (psychiatrist, and chair of the committee that oversaw the new manual) said:

“In the future, we hope to be able to identify disorders using biological and genetic markers .. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”

Despite psychiatry’s efforts to conceal this problem, there are certain situations where it becomes obvious. One is when mental illness is proposed either as cause or mitigation in criminal trials. When this occurs, either prosecution or defence must prove that their client is ill (or not).

An exceptionally high-profile instance of this occurred in 2012, when Norwegian right wing terrorist Anders Breivik was found guilty of murdering 77 people. The trial took more than three months, with a lengthy period taken up debating whether or not Breivik was mentally ill (and if so, in what way). As the debates clearly showed, these questions could not be settled by simply carrying out, say, a blood test or brain scan. Fundamentally, this was because there are no consistent biological differences – no biomarkers – that any scan or test might assess.

For at least six decades now, psychiatric research has received significant financial support from the pharmaceutical industry (including its advertising campaigns). It has been relatively generously funded by governments, too. It has also had increasing access to ever-more sophisticated and powerful new technologies, such as brain imaging and genome scanning.

Unsurprisingly, all this has paid off. It has persuaded some people to imagine that they have faulty brains, rather than awful lives. It has generated massive profits for pharmaceutical companies. It has provided politicians with a smokescreen that helps conceal the toxic effects of capitalism. But what it has not done is scientifically demonstrate that the experiences psychiatry calls mental illness can be traced back to biological defects, impairments or diseases.

Questioning the Politics of Depression

This is why some UK psychiatrists have rejected the idea that distress is caused by biological vulnerabilities. They have formed the ‘Critical Psychiatry Network’, and forged alliances with service user groups such as the ‘Hearing Voices Network’, who also reject the view that the causes of distress are primarily biological. Many clinical and counselling psychologists in the UK, and most social workers, are also wary of claims of biological causation.

Yet the wider profession of psychiatry continues to forcefully promote the belief that distress is biologically caused. When they do this the scientific evidence gets misrepresented, and critics get falsely accused of lacking compassion, blaming families, or cruelly denying people the (drug) treatments they supposedly need.

It should be no surprise that psychiatry wants us to believe in depression and other mental illnesses: there is a lot at stake. This belief underpins the considerable power and influence of psychiatry. It legitimises the revolving-door connections between ‘pure’ biological and neuroscientific research, and big pharma. It justifies expensive research programs that, in turn, advance psychiatric careers. Under capitalism, frequently, it is also politically convenient. So although more than sixty years of research have failed to produce any good scientific evidence for this belief, what this failure means is disputed. For those with an interest in the status quo, it mostly means that we should commit even more time and money to the desperate search for biological causes.

This begins to show why conceptualising distress as a psychiatric illness, for example depression, is politically unhelpful. Doing so works to justify the vast profits of the pharmaceutical industry (estimated at $1.6 trillion in 2023: equivalent to the GDP of Australia). It makes offering psychiatric drugs as the default response to misery superficially more reasonable. It obscures the intricate connections between how people feel now and what happened in their pasts. It paints understandable reactions to difficult circumstances as symptoms of an illness that only affect those with biological vulnerabilities – it medicalises them.

Medicalisation, in turn, does three more things. First, as we have seen, it thoroughly de-politicises distress. Second, it obscures how complex, dynamic mixtures of toxic circumstances, including the effects of prior experiences, can produce enduring states of misery. And third, it encourages an ‘us and them’ thinking that fosters discrimination and stigmatisation. In so doing it also conceals a discomforting truth: the experiences that attract a diagnosis of depression could one day befall any of us.

In a society where psychiatric beliefs are hegemonic (widely accepted as common sense), temporarily using the concept of depression can sometimes bring advantages. It might serve as a ready–made explanation, a kind of shorthand, for terrifying depths of misery. It might open the door to mental health services (although these have been savagely cut). And it might help manage the DWP, preserving access to benefits at something more than subsistence level.

In these kinds of situations, tactically using the concept of depression makes good sense. But, returning to the main theme of this article, it makes no sense to use it in discussions amongst activists. Using a psychiatric reification like ‘depression’ medicalises distress, which immediately neutralises its political character. It makes distress an effect of supposed individual pathology, rather than a consequence of difficult experiences. This means that it prioritises fixing (hypothetical) biological defects over changing the social, material and economic circumstances that activists strive to improve. This means that it can only impede progressive political conversations.

Leaving Psychiatry Behind

Instead of using concepts from the pseudo-science of psychiatry, activists would be well-advised to consider alternative models of how distress is produced and maintained. The Power Threat Meaning Framework (PTMF) was explicitly devised as an alternative to psychiatric diagnosis. The PTMF understands distress as experience, not illness. Like all experiences, distress is shaped by circumstances largely beyond individual control. It arises when combinations of social, relational and material influences, contingently arranged by relations of power, are mediated by personal meanings to produce threats. The PTMF recognises that distress is individually experienced and intimately, personally, painfully felt. Yet it does not locate the causes of distress within the supposedly faulty biology of individuals: it sees them as arising in dynamic combinations of environments, circumstances, biographies and social relations.

Activists might also benefit from knowing about some of the evidence linking social, economic and material factors to distress. It is well established that the likelihood of experiencing distress varies according to factors such as biological sex, ethnicity and social class. Distress is more common amongst the poor, the disadvantaged and the marginalised – migrants, for example – and its prevalence is greater in countries where social inequality is higher.

At the same time, distress is more likely following early experiences such as abuse, physical or emotional neglect, and trauma. It also occurs more often after adverse life events such as bereavements, relationship breakdowns and accidents, and amongst people with physical disabilities. More amorphous influences contribute, too: particularly, a relative lack of love and solidarity to shield, comfort and compensate. Importantly, though, distress is not forced to be associated with any of these things (although the more adverse experiences someone has, the more likely it becomes).

The evidence also shows that there are cohort effects in distress – effects shared by people born at around the same time. Cohort effects are particularly significant for activists because they are evidence that distress is not mere individual pathology. They show how distress is influenced by politics, economics and history. One Australian study showed that suicide rates went up under Conservative governments, and down under Labour ones. In the UK, there is evidence that today’s young adults – who are both the frontline victims of neoliberalism and the COVID lockdown cohort – are more distressed than previous generations. An estimated 20% of the UK’s 8-16 year olds now report some notable degree of distress, compared to 12.5% in 2017.

Where is the Left?

You might expect that the Left would be entirely receptive to the kind of critique presented here. But disappointingly, the UK’s two largest left-wing parties – just like the right-wing Conservatives – endorse psychiatric concepts of diagnosis and treatment.

The Labour government’s manifesto commitment  is to “bring waiting times down and intervene earlier. We will recruit an additional 8,500 new staff to treat children and adults through our first term….Labour’s new Young Futures hubs will provide open access mental health services for children and young people in every community….. we will provide specialist mental health professionals in all schools”.

And the Green Party, often more radical than Labour, on this issue is barely distinguishable from them. Their uninspiring goal is to put “mental health care on a truly equal footing with physical health care. This will include ensuring that everyone who needs it can access evidence-based mental health therapies within 28 days.”

Surprisingly, the farthest-reaching proposals for effective political action on distress can currently be found in the charity sector. A report by the Mental Health Foundation showed “a clear link between effective anti-poverty measures and improved mental health.” A £50 weekly payment cut mental health difficulties by 6%, while a £100 payment improved mental wellbeing by 13%:

“The results of this study show this type of policy would deliver a genuinely impressive drop in the number of people struggling with poor mental health, with tens of thousands of people being lifted out of needing clinical support.”

Evidence-based suggestions such as this provide a powerful challenge to Labour’s intended benefit cuts, and we might have expected activists to take them up enthusiastically. But maybe it is still too radical to state openly that many people are suffering, not so much from ‘mental health problems’ as from poverty?

Is the Left Right?

The Left’s lacklustre, unimaginative response to what many are calling a mental health crisis is in part a reflection of the political shift, what Moncrieff called the “curious metamorphosis”, that seems to have recently occurred. Whichever way you look at it, for much of the Left to go so rapidly from critiquing psychiatry to actively valorising psychiatric diagnosis (including self-diagnosis) is a striking development. What is going on? It is beyond the scope of this blog to detail all of the social and cultural forces driving this U-turn, but three possible factors of general relevance will briefly be discussed.

First, the decline of the organised Left (i.e the left wing of the Labour Party,  the extra-parliamentary activist milieu and left wing organisations, but not the current, nominally left wing Labour government), an international phenomenon symbolised in the UK by the vanquishing of Corbynism in 2019, seems to have had a similar effect to previous defeats and withdrawals. In particular there has been a loss of confidence, coupled with a partial turn away from wholesale societal and economic transformation, and an emphasis instead upon smaller-scale issues and campaigns where successes may still be possible.

Second, this has accelerated the rise of identity politics, and in particular the ways in which certain psychiatric diagnoses are now much sought-after identities. The astonishing proliferation of this phenomenon – across both sexes, all classes and most age groups – is accompanied by narratives of rebirth, of an end to uncertainty and of the discovery of the true self. These narratives illustrate how the putative advantages of these diagnostic identities might play out materially, institutionally and interpersonally. Simultaneously, their bland one-sidedness starkly illustrates their thoroughly ideological character.

And third, we have the psychological damage still being wrought by the continued dominance of neoliberal capitalism: the terrifying uncertainty of precarious work, the immiseration of poverty wages, the evisceration of public services, and so on. Up until 2019 and the end of Corbynism it was possible to imagine that something better might replace this brutal system. Then Corbyn resigned as Labour leader, although attacks on his character and policies continued unabated for some years. Their purpose was quite obviously not to depose him: rather, to systematically eradicate every last vestige of hope for, and belief in, progressive alternatives.

In these quite literally hopeless circumstances, what Mary Boyle has called the ‘brain or blame’ dilemma compels the increasing numbers struggling to get by to align themselves with one of two positions. They must embrace the psychiatric concept of mental illness as brain disease, defect or impairment. Alternately, they must risk their terrible suffering being dismissed as the consequence of a personal failing, a moral weakness, a character flaw – as ‘all in the mind’. Faced with this loaded choice it is understandable that many would favour psychiatry.

So since 2019 the Left became more timid and narrowly focused, and this invigorated the turn to identity politics. At the same time, identities founded in psychiatric diagnosis were made ever more salient by the rising tide of distress that neoliberalism continued to engender. Add to this the habitual vanguardism and opportunism of many Left organisations, and we can see how pressure to embrace psychiatry, rather than to critique it, would arise.

Yet nothing in that explanation changes the basic facts. Ever since its inception, the fact is that psychiatry has predominantly functioned as a technology of social control. Today, psychiatry still polices and defines deviance, it still sets the boundaries of normality. Psychiatry today, just as in previous decades, is thoroughly co-dependent with the pharmaceutical industry. And today, as they have always historically done, psychiatric diagnoses medicalise and individualise, and therefore de-politicise, the difficulties of those struggling to adapt to the rapacious demands of neoliberalism.Both objectively and materially, psychiatry furthers the interests of capitalism.

Conclusion

Mark Fisher’s 2014 book ‘Capitalist Realism’ opens by saying that “It’s easier to imagine the end of the world than the end of capitalism”. Although Fisher took his own life in 2017, both his ideas and his experience have been influential for this blog. Despite suffering for many years with what psychiatry calls depression, Fisher never endorsed this psychiatric concept. Instead, he favoured the kind of explanation put forward by clinical psychologist David Smail. While David died in 2014, his ideas have been vitally important throughout this piece.

Mark Fisher’s work will be familiar to many activists already; David Smail’s less so. While activists familiarise themselves with these ideas, they might usefully commit to following the advice of psychiatric service user, survivor and campaigner Jacqui Dillon. Instead of trying to understanding people’s distress by thinking “what is wrong with you?”, Jacqui proposes that we should be thinking “what has happened to you?” This simple change of focus would, by itself, go a long way in helping activists to better understand the dynamics of distress under capitalism.

This article was first published on the Mad In The UK site

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