The Medicalization of Mood: Psychiatric Uses of the Diagnosis of Bipolar Spectrum Disorder in Iran Fahimeh Mianji Division of Social and Transcultural Psychiatry – Department of Psychiatry McGill University Montreal, Quebec, Canada November 2020 A thesis submitted to McGill University in partial fulfillment of the requirements for the degree of Doctor of Philosophy (PhD) 1 Supervisor Laurence J. Kirmayer, MD James McGill Professor Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University Advisory Committee Joel Paris, MD Professor Department of Psychiatry, McGill University Danielle Groleau, PhD Associate Professor Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University Allan Young, PhD Professor Emeritus Departments of Social Studies of Medicine, Anthropology & Psychiatry, McGill University Local Mentor Azarakhsh Mokri, MD Associate Professor Department of Psychiatry, Tehran University of Medical Sciences 2 TABLE OF CONTENTS ABSTRACT .................................................................................................................................................................. 6 RÉSUMÉ DE LA THESE ........................................................................................................................................... 9 ACKNOWLEDGEMENT ......................................................................................................................................... 13 CONTRIBUTION TO ORIGINAL KNOWLEDGE .............................................................................................. 17 CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW ...................................................................... 19 1.1 INTRODUCTION ................................................................................................................................................... 19 1.2 LITERATURE REVIEW .......................................................................................................................................... 21 1.2.1 Iranian Mental Health Infrastructure ........................................................................................................ 21 1.2.2 A Short Overview of the History of Psychiatry in Iran .............................................................................. 24 1.2.3 A Short Review of Contemporary Psychiatry in Iran ................................................................................. 25 1.2.4 The Pharmaceutical Industry & Pharmaceutical Consumerism ................................................................ 27 1.2.5 Iran’s Pharmaceutical Market ................................................................................................................... 28 1.2.6 Pharmaceutical Consumerism .................................................................................................................... 32 1.2.7 Iran: Social and Political Context, Gender Disparities, and Family Values ............................................. 33 1.2.8 The Medicalization of Mood: An Overview of the Controversy Over Bipolar Spectrum and “Soft” Bipolarity ............................................................................................................................................................. 37 1.2.9 The Prevalence of Mental Disorders in Iran .............................................................................................. 40 1.3 OBJECTIVES OF THIS STUDY & RESEARCH QUESTIONS ...................................................................................... 43 1.4 THEORETICAL FRAMEWORK ............................................................................................................................... 44 1.5 METHODOLOGY .................................................................................................................................................. 47 1.6 STUDY SITES ....................................................................................................................................................... 48 1.7 SAMPLING AND PARTICIPANTS ........................................................................................................................... 49 1.8 ETHICAL CONSIDERATIONS ................................................................................................................................ 52 1.8.1 Approval from Ethics Boards ..................................................................................................................... 52 1.8.2 Confidentiality ............................................................................................................................................ 52 1.8.3 Dissemination of Research Results ............................................................................................................ 52 1.9 DATA COLLECTION ............................................................................................................................................. 53 1.10 DATA ANALYSIS ............................................................................................................................................... 54 1.11 METHODOLOGICAL LIMITATIONS ..................................................................................................................... 55 REFERENCES ........................................................................................................................................................... 56 CHAPTER 2: THE GLOBALIZATION OF BIOLOGICAL PSYCHIATRY AND THE RISE OF BIPOLAR SPECTRUM DISORDER IN IRAN ......................................................................................................................... 68 2.1 ABSTRACT .......................................................................................................................................................... 68 2.2 KEYWORDS ......................................................................................................................................................... 69 2.3 INTRODUCTION ................................................................................................................................................... 69 2.3.1 Background ................................................................................................................................................. 71 2.4 METHODS ........................................................................................................................................................... 77 2.5 THE EMERGENCE OF THE BIPOLAR DISORDER DIAGNOSIS IN IRAN .................................................................... 79 2.5.1 Key People and Institutions ........................................................................................................................ 80 2.6 CONTROVERSY OVER THE USE OF BSD IN IRAN ................................................................................................. 84 2.7 STRUCTURAL FACTORS IN THE OVER-DIAGNOSIS OF BIPOLAR DISORDER IN IRAN ............................................ 88 2.7.1 Psychiatric training in Iran ........................................................................................................................ 89 3 2.7.2 The Pharmaceutical Industry & Pharmaceutical Consumerism ................................................................ 94 2.7.3 Political and Ideological Factors: Medicalization and Social Control ..................................................... 99 2.8 CONCLUSION ..................................................................................................................................................... 102 2.9 ACKNOWLEDGEMENTS ..................................................................................................................................... 107 2.10 CONFLICT OF INTEREST .................................................................................................................................. 107 REFERENCES ......................................................................................................................................................... 108 INTRODUCTION TO CHAPTER 3 ...................................................................................................................... 119 CHAPTER 3: “WOMEN AS TROUBLEMAKERS”: THE HARD SOCIOPOLITICAL CONTEXT OF SOFT BIPOLAR DISORDER IN IRAN ............................................................................................................... 121 ABSTRACT .............................................................................................................................................................. 121 KEYWORDS ............................................................................................................................................................. 122 3.1 INTRODUCTION ................................................................................................................................................. 122 3.1.1 Background ............................................................................................................................................... 122 3.2 METHODOLOGY ................................................................................................................................................ 126 3.3 RESULTS ..........................................................................................................................................................