Depression is back in the news again, thanks to the recent revelation that 2012 saw the highest ever number of antidepressant prescriptions in England – more than 50 million, apparently. This had led to an orgy of ill-informed comment (most of which I have encountered in scattered corners of the internet, and none of which I still have the links for: sorry). As a person diagnosed with depression, I find this exquisitely annoying. So, this post is me answering back, for the sake of my own mental equilibrium. It’s basically the online equivalent of me wandering round a shopping centre muttering to myself whilst looking unshaven and a bit weird so, you know, feel free to back away slowly…
There is no epidemic of clinical depression. There is an increase in the number of prescriptions for antidepressant medication. Antidepressant meds are prescribed for a whole range of conditions, including Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, any of the various different flavours of anxiety disorder, some chronic pain conditions, and I’ve even heard of GPs prescribing some of the sedating meds as non-addictive sleeping tablets for people with insomnia.
So, to summarise: more antidepressants does not necessarily mean more depression.
Then, too, an increase in the number of prescriptions doesn’t necessarily indicate an increase in the actual number of tablets being distributed to patients. It might simply reflect that prescriptions are being issued for smaller amounts of drugs, perhaps because GPs are monitoring their patients more closely, rather than abandoning them to bi-monthly repeat prescription limbo. In fact, look at the relevant table in the publication that sparked the news stories – Prescriptions Dispensed in the Community: England 2002-12, page 29 – and you’ll see that the 7.5% increase in the number of prescriptions was accompanied by a 21.8% decrease in the cost. That could reflect a number of things – patients being shifted to cheaper drugs, patients being shifted to generic versions of drugs, drugs coming out of patent protection – but one of the things it might reflect is that patients are being issued with more prescriptions for the same number of drugs.
So, to summarise: more prescriptions does not necessarily mean more antidepressants.
Clinical depression is a wilfully misunderstood condition. It’s wilfully misunderstood by both the medical/ psychiatric profession and psychologists/ therapists who, for different reasons, have conspired together to strike out the distinction between reactive and endogenous depression.
Reactive depression is when you feel bad because a bad thing (or a whole sequence of bad things) happens in your life. Endogenous depression is when you feel bad for no reason whatsoever.
Psychiatrists were happy to see the distinction erased, because it meant even the most trivial and transitory of low moods could be treated by their drugs. Psychotherapists were happy to see it erased, because it placed even the most severe cases of depression firmly within their bailiwick. But the difference persists despite the best efforts of both.
Reactive depression is horrible, but it’s also a sign that your emotions are functioning as they should. In reactive depression the only thing that can lessen the pain is getting out of the situation that’s making you feel bad, or getting some distance and perspective on events you’ve endured. Handing out antidepressants to someone who’s just lost their job, their home, and their spouse in a series of connected events is a futile exercise: they don’t have a medical problem, and they can’t be cured by medical means. Time, space – and maybe a friend with a bottle of whisky, and patience to burn – can help.
Endogenous depression, meanwhile, is a sign that your emotions are malfunctioning. If you have no reason to feel depressed, but still spend your days in a constant fog of misery, there’s something wrong. A friend with whisky won’t cut it but, if you’re lucky, antidepressants might. That meta-analysis from a few years back which every media outlet at the time said showed that antidepressants are junk actually showed that they are effective in severe depression. They just don’t work when you’re feeling moderately depressed because you hate your job.
I have no wish to turn this blog (back) into a misery memoir, but I’ve known both reactive and endogenous depression in my forty years on this planet. I’ve known the low mood that results from bereavement, losing a job, mortgage repossession, and the break-up of a 10-year relationship (what a fun two years they were). I’ve also known the low mood that strikes for no reason out of a blue sky, and they are completely different.
They’re qualitatively different. Reactive depression is an active sensation of emotional distress, endogenous depression a passive sensation of utter desolation and hopelessness. Reactive depression is “clean”. It’s a feeling of emotional distress, and that’s it. Endogenous depression is “dirty” as all hell. For me, it comes with a side-order of crippling anxiety, paranoia, whispering voices, and mysterious strangers who disappear as impossibly fast as they appear. Reactive depression is me, sad. Endogenous depression is me, utterly bereft, panicking seventeen different ways to Sunday, convinced the world is out to get me, and struggling to tell the difference between what’s real and what’s fake.
Then, too, they’re different in their effects. I could function after a fashion when I was reactively depressed. I could get out of bed, imagine a future, make plans for it and carry them through. When my endogenous depression is at its most severe I am robbed of any sense of a future at all. I endure day-by-day, moment-by-moment, even. The most basic of self-care tasks become almost insurmountable.
When I was reactively depressed, swallowing fluoxetine was like swallowing smarties. When I was endogenously depressed, very high doses of lofepramine helped a bit. For a few months, at least, until the effect gradually drained away, and I was left without even that.
It’s not just healthcare professionals who misunderstand clinical depression, the wider culture does it, too. To the newspaper commentariat, depression is “simply the latest name for that incurable condition called life”. Depression is an affectation, or the new name for malingering. Unless it drives someone to suicide, and causes knock-on delays on the commute home: then it’s selfishness instead.
To the wider culture, the very worst clinical depression is “those feelings of unhappiness we all experience from time to time”. The cure for depression is to “snap out of it”, or take a walk, or treat yourself to an ice-cream, or watch a funny film, or “count yourself lucky you’re not living through the blitz, then you’d really have something to moan about”.
To be clinically depressed is (supposedly) to have a spurious diagnosis invented by snake-oil salesmen – not to have a condition that is exploited by snake-oil (and talking-snake-therapy) salesmen.
To be clinically depressed is to have been taken in by “big pharma” – who are not a group of large companies taking rational if unethical steps to maximise their profits, but a sinister conspiracy amongst… sinister conspirators to be… like… conspiratorial, and… sinister, and… stuff.
To be clinically depressed is to win the mental illness lottery: “Congratulations! you don’t have schizophrenia, bipolar disorder, an eating disorder, OCD… Think how much worse it would be if you had one of the really bad ones…not that depression isn’t bad, but, you know, one of the serious ones…”
Severe endogenous depression is, mercifully, somewhat rare. It affects a relatively small number of us who get the label “Depression” stamped on our foreheads by diagnosticians. Most people diagnosed with depression will recover in relatively short order – the placebo boost of an SSRI, maybe a short course of therapy, and they’ll be up, up and away in their beautiful balloon. Most people will have no opportunity to become acquainted with the other sort of depression: the one that robs you of your future, and of the ability to take pleasure in the present; the one that grinds on for week after month after year, and comes, in some cases, with a side-order of psychosis.
If there is an epidemic of depression, it will be an epidemic of the reactive kind, but I’ll bet there’s actually an epidemic of neither. I’ll bet what there’s actually an epidemic of is an epidemic of it being August. There’s an epidemic of empty news pages to fill, and
– “Quick, someone, scrape together some witless blathering on that press release on antidepressant prescriptions – you know, worrying insight into the psyche of the nation, contradicted by the happiness stats, then a comment piece about how someone’s wife’s brother’s daughter’s girlfriend’s lodger’s cousin’s boss’s mother claims to be depressed and gets gold-plated disability cheques for life even though she’s out dancing every night” –
is always an easy go-to for the socially irresponsible editor in a hurry.
I know, I rambled. I don’t care.
Bad blogger. Go straight to gaol. Do not collect
200 20 2 hits on the stats counter.
A public service announcement:
If you’re feeling depressed – please get help. If you don’t think you’re depressed, but some of the things I said in the main bit of the post really resonated with how you’re feeling right now – please get help. Speak to a doctor, or a friend. Google ‘mental health help’ and look for the local services that are listed – helplines, and so on. Thank you.