The morals of medication

Is taking medication for depression the ‘easy option?’ I come across this viewpoint regularly on social media. Usually there is a suggestion alongside that therapy, which I completely agree is hard work, is somehow a purer way to recover. The right way.

The history of psychiatry is rich in references to morality. Is a person ‘mad’ or ‘bad’? Is there really something wrong in the brains of those society labels as bad? Is addiction an illness or simply a behaviour choice? Are we excusing bad behaviour by medicalising it?

Many people who consider medication for depression will find themselves wondering whether it is a ‘good’ thing to take it. When you are depressed it can be very difficult to decide what is the best thing to do, and decisions are taken not only on the basis of discussion with health professionals- moral judgments also play an important part.

  • How does taking antidepressants affect how I feel about me? Does it mean that I am weak?
  • Is it the easy option?
  • Shouldn’t I be able to sort myself out without them?
  • What will other people think- my family- my friends…will it change how they see me?

Alice Malpass and her colleagues identified two parallel journeys that the depressed person embarks on. The ‘medical’ journey goes something like this:

  • I have a duty to be well. Other people need me to be well.
  • If I recover then there won’t be any risk of being seen as ‘mentally ill’.
  • I can get back to my old self and be in charge of my life again.

I’m sure I’ve used some of these arguments in conversation with patients. Any doctor who says they haven’t is not telling the truth- but to consider these are the only things of concern about medication is inherently simplistic and paternal, and reminds me of the cartoon of a couple walking along a beach, smiling and carefree, who say they feel so good they must be in a pharma advert.

In parallel the person is perhaps also on another journey- the ‘moral’ one.

  • I feel awful because I have to ask for help.
  • I feel even worse because I need to take tablets.
  • Is this person the real, authentic me? Am I now my old self or someone else? Or am I only this person because I am on tablets?
  • Am I hooked on these now?

Damien Ridge, who has analysed many interviews with people who are depressed talks not only about the lack of legitimacy for tablets, but also for what they are being prescribed for.

  • Is ‘depression’ real?
  • Shouldn’t I just ‘pull myself together’? Isn’t that what everyone else thinks?

There is a great deal of literature on whether ‘depression’ is ‘real’ or simply no more than unhappiness. And if it isn’t real, then the treatment for it cannot be legitimate either, little better than using street drugs- as one person in Ridge’s paper calls his tablets: ‘My dirty little habit’. I’ve spent my career arguing that to use the term depression is not simply medicalising misery but giving a name to a particular experience and quality of suffering which is not just unhappiness but a deep, dark, hopeless, despair. It has many causes, and it isn’t a single ‘phenomenon’ whatever DSM tells us. But it’s a state of mind that many people with different stories share in common. I experience it too. I have asked all of these questions of myself. I have watched colleagues who work in mental health look a little embarrassed when I get out the tablets at breakfast. Perhaps I do that simply to show I am not ashamed- but I do wish I could have lived my life without them.

All of the above supposes that antidepressants do actually work. Many people think they don’t, and others think they can do harm. You can find my views on these points elsewhere on this blog. I take them myself and they keep me reasonably well, but I have friends and colleagues for whom they have not worked- the medical journey is inherently optimistic- just like the pharma ads, but in reality life is far more complicated. And they are never sufficient on their own.

If doctors, and sometimes friends and family, try and influence you to focus on the ‘medical journey’ then others will try to steer your moral journey. It is really hard to focus on what is right for you when you cannot think clearly. When you are depressed, you are already struggling with guilt and shame and sometimes that can tragically end with the decision that the world is better off without you- that this is the right thing to do.

So I would only ask those who make even subtle comparisons between the easy way to ‘block out the pain’ with meds and the hard way of suffering through therapy to think before they write. It is only human to want to alleviate pain, and sometimes the tablets are the only thing that will do it. To infer that a person needs to suffer in order to be blessed is one of the ultimate moral judgments- and can be found in most religions.

Depressed or not, clinician or service user, expert or lay person-none of us have the right to sit in judgment over others.

My memoir: The Other Side of Silence: A Psychiatrist’s Memoir of Depression is available now.





9 thoughts on “The morals of medication”

  1. Part of more wants to email a link to this to my dad, another part thinks that doing so will just open up a can of worms!! His aim is that I an med free. He constantly problem solves my life!! Today he’s questioned whether I should have done less on Sunday, just cos I’m tired. The fact that work anxiety will subconsciously tire me hasn’t even crossed his mind! People see mental health and the treatment of mental health as black and white, right and wrong…but actually there is a lot of grey, a lot of mess.

  2. Hello,

    I’ve just finished your book, which I found really comforting. I think I am one of those “depressed personalities” you dealt with in your book. I’ve been feeling lower than usual for quite a few months now (since September). I don’t really know what to do. My life has been difficult to deal with and I feel like I’m just screwing everything up. Slightly. Smoothly. But still, unable to get back on tracks. That’s weird. Dysthemia, depressed personality, depression, or just lower mood?What I’d like to know, according to you, when is the right time for somebody to ask for help/get support?
    To be quick: I’ve spent a lot of time in my bed since December, I have problems with food (compulsive eating but obsession over getting thinner and thinner), I used to drink far too much between October and December, but I stopped that in January and got interested in my weight instead… Can’t do my work properly. Can’t stand anybody, avoid social interactions. Feel quite trapped in life, not to say hopeless about the future. I feel more trapped than hopeless. But maybe it is related…
    You know, I don’t really know how I feel, right now. So I think that maybe my state isn’t serious enough to get support. But at the same time, I don’t feel normal… I won’t tell about my life any longer, I just hoped that maybe you might read that and help me in finding out whether or not I should get support… It doesn’t have to be a long answer, just a “Yes you should”/”no, you can still find ways to cope with, trust yourself” would be enough. I don’t know who to talk to (see, I’m desperate enough to go and ask a complete stranger for help instead of asking my acquaintances… Who do not have the expertise, nor the listening skills…). I wish I could find a therapist like you. Never happened. Maybe once, but he didn’t stay long and I don’t remember his name. Too bad.

  3. Sophie, I cannot provide a simple answer. It wouldn’t be right for me to try. I cannot give people advice on here. But it sounds like you need to have this conversation with someone who can help you make the right decision about what is best for you. That may or may not be a therapist, but if you are feeling desperate, it sounds like it should be a mental health professional.

    1. Yeap, I am sorry, my comment must have seemed inappropriate. Sorry for that.

      Anyway, I have read your memoir and I really found it useful: both emotionally because it was comforting to read about people who are undergoing similar painful experiences, hearing their voice was highly beneficial because people rarely talk about their inner reality and we are all lost in our own single despairs. Which is a pity. It was also useful and interesting to have the point of view of a professional, it helped me to step back on those experiences and gave me some tools and knowledge. I have read several memoir about depression, and I am reading another one again, right now. But among all the memoirs I have read, I felt that yours was the most humane, humble and useful for me. That’s only my own little subjective opinion.

      Thank you for sharing both your personal experience of the disease and your professional point of view. The combination of these two made the book a very enlightening reading, for me. Thank you.

      And sorry if I may have sound inappropriate, don’t hesitate to delete the comment. (ps.: sorry for the mistakes I may have made, I am not a native English speaker)

  4. I tweeted you something appreciative a couple of weeks back, about your blog post on power threat meaning. This is the 2nd piece of yours I’ve read and it’s even better. I have a paid job in the Hearing Voices ‘movement’ and my opinion is that medicalisation of the human condition does, ultimately, more harm than good. That said, I am, much of the time, deeply out of ‘sync’ with the language and culture of that surrounds me in radical activist circles. Changing the world is not my scene and I yearn with all my heart for a voice like yours on our side of the ‘fence’ (if there is a fence). Thank you you are a breath of fresh air.

    1. Thank you! I’m a psychiatrist, so I take a medical perspective too, but it is strongly tempered by my own experience and that of the many people who use services who are in contact with me. I try to maintain some kind of balance but sometimes its not easy.

  5. Surely you don’t think the only explanations for depression are that it’s either a disease or a moral failing? I see this straw man argument all the time. It seems biologically-orientated psychiatrists don’t actually want to acknowledge many of the legitimate points made by others. For example, there are compelling justifications that depression is a useful evolutionary adaptation under intolerable situations that forces us to change our circumstances. Others see the problem within the environment and the social structure so not even within the individual. Similarly, victims of bullying and narcissism can become depressed and many would argue this occurred because of the victimisation rather than faulty brain chemicals. I’ve rarely ever heard anyone accuse those with depression as having moral failings and, in fact, I find the dissenting voices are often infinitely more compassionate and more reassuring that the way I’ve felt is not my fault. So, can we stop using this straw man? People who don’t believe depression is a medical problem don’t believe it’s not real at all. They believe it’s very real but view it through different eyes. Suffering doesn’t have to be medical to be legitimate, and it’s a shame if anyone thinks otherwise. I am sorry that you viewed your own depression as resulting from moral failing if it couldn’t be termed as an illness. My experience was different and I found I learnt and grew from the experience, as difficult as it was. I came out the other side. I’m stronger now. I recognised what triggered the episodes and I have reflected enough that I hope I can avoid them again. But if it wasn’t for depression, who knows what I’d be doing with my life now. I’d probably be far less authentic than I am now, trudging away in a job that I never quite felt sufficiently pushed to leave. Depression has brought me closer to my true self and for that I am thankful.

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