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.

 

 

 

 

Authenticity

Oxford dictionary: Authentic – adjective: ‘relating to or denoting an emotionally appropriate, significant, purposive, and responsible mode of human life’.

My 60th birthday has come and gone. My body is beginning to fall apart but I still feel 16 inside. Life is a ‘work in progress’, or at least that is how it has always seemed for me. I get depressed from time to time and it’s such a truly awful experience that it’s hard to believe there can be any positives from suffering it, even if evolutionary biologists suggest there might be. But I recognise that its impact on my life has enabled me to begin to see more clearly what is really important : my relationships and my writing.

When you are someone with mental health problems it can be difficult to work out who is the real ‘authentic’ version of you. Even if people aren’t really talking about me, am I the oversensitive person who will always think they are? Or maybe that is one side of me, amongst many different faces. There are times still when I wonder whether the medicated me I’ve been for so long is the ‘real’ me, or are these tablets simply suppressing the person I truly am? When I worked in addictions people would ask me the same kind of questions.

‘Who will I be without the alcohol? Will I be able to live with myself? Will other people?’

‘Why am I so different when I’m drinking heavily? Yet sometimes that feels like the real me- the one who is trying to get out and cause havoc?’

One of my patients used to give me brutal feedback about the colour of my nail polish (I had a gothic period- which on reflection I’m still passing through) when she was going high. When she was well she would insist on apologizing when she really didn’t have to- she was just expressing another, very perceptive, part of herself that was usually kept in check.

When my mood is irritable and agitated, I can come out with the kind of comments that would be much better left unsaid- and certainly not shouted. From psychodynamic therapy I learned about the parts of me I was repressing, but they don’t have the best of social graces. In cognitive therapy I found ways to manage the way I ruminate about being me in this world. It’s far from a perfect fit, but who is to judge what is perfect?

Damien Ridge highlighted 4 different aspects of recovering from depression after talking to people who were, or had experienced it. (I am talking here about recovery in its original meaning as a personal journey not a service driven imperative).

  • Preventing depression from occurring in the first place
  • Limiting the impact of actual episodes of depression
  • Recovering from the effects of depression in the short and long term
  • Re-working the self so that is more functional or authentically felt

I haven’t succeeded in preventing episodes and, as one reviewer commented about my book, perhaps it would be fair to say my story illustrates well the limits of medicine. Neither talking nor tablets, separately or together, have provided a complete answer. My current doctor thinks I would have been in hospital over the last few years without the treatment I’ve had, and I think he is probably right. I can limit the impact of episodes now, and I’ve been able to live and work while experiencing bouts of depression.

I cannot always remember what the ‘depressed me’ is like until she wholly inhabits me once more. I can only say that being ‘her’ is not a good feeling in any way, it means feeling cut off from the rest of the world, unable to communicate, as though there is a thick ground glass screen between me and the rest of life. I can hear and see something of what is going on but I don’t feel any part of it, and it fills me with fear. I don’t want to be her, and so far I’ve managed to get away from her much of the time in the last 20 years, but has that been the right thing to do?

The writer Will Self, who is fiercely against taking tablets for depression has said that ‘from the stand point of the 20th century, to be melancholic is good mental health’. He has been able to employ his own personal experience of it to gain insights into extraordinary ways of viewing the world. Would I have had a different perspective on life if I had persisted in trying to cope in a different way? For instance by writing, painting my way out of depression or seriously learning how to meditate – or even, dare I say it, attempting to rediscover the faith I had as a teenager?

The problem I have is that it’s been nigh on impossible to open a book when I’ve been severely low, never mind sit down at a laptop and type. I would love to have been able to write my way out of depression, but it’s not possible for me. I can only work when I’m ‘well’ and I cannot help but see the world through the lenses of the treatment I have had- the ideas I have taken on board from therapy, and in particular the medication I still swallow every morning and evening. They certainly seem to alter my perception of the world in some way to make it a less hostile place.

For thirty years my major role in life was being a doctor. It both satisfied me and punished me. The thought that I might ever have to return to work again as a doctor fills me with anxiety, but I’m still registered with the General Medical Council. The alternative was being ‘erased’ which sounded like I had done something wrong, when I hadn’t. The act of giving up my work as a health professional stands in the way of what I’ve felt was my raison d’etre – helping other people.

Last month, more than 2 years after retiring, I shredded all the paperwork relating to my annual appraisals over the last 15 years (or whenever they began). There is no going back even though I miss that sense of being part of the ‘real’ world on the front line of health care. Now I have time to find out more about the person I really am and what I want to do next. There is some important unfinished business with my ‘self’.

“The privilege of a lifetime is to become who you truly are.” C.G Jung

My memoir on depression and psychiatry: The Other Side of Silence- A psychiatrist’s memoir of depression, is available now.

 

 

I’m a psychiatrist and I live with depression

I am a psychiatrist, and I’ve had depression on and off for most of my adult life. I’m now retired from practice. I’ve written about depression in a book, and people are saying how brave I am to ‘come out’ and say it. Yet if I had written about having arthritis, or some other physical condition, no one would have described my ‘coming out’ in such terms. Why should it be such a surprise that a a person who worked as a consultant psychiatrist for almost 25 years, and has spent her life researching and teaching the subject, should have first hand experience of it herself? Probably because, in the health professions, the last thing we usually want anyone to know, particularly our colleagues, is that we too are vulnerable to exactly the same stresses and problems as our patients. We like to see ourselves as strong; indeed maintaining our position on the career ladder often seems to depend on that. There is stigma related to having depression, even though mental health workers profess that they are always ‘fighting’ it. Depression is something that others suffer from, not us.

It is exactly this ‘us’ and ‘them’ attitude that I set out to challenge in the book. It started off as a memoir of my own fairly extensive treatments for depression, both with medication and psychotherapy. However as I began to write it, the close parallels between my own experiences, and those of the people I had tried to help throughout my professional life just became more and more obvious to me. There certainly wasn’t a clear boundary between my own experiences and those of my former patients. We all had complex lives- experienced loss, grieved for those who have gone from our lives, felt lonely, wanted to be loved, and sometimes felt compelled to self medicate with alcohol to ease our distress. Some of us made the same mistakes in our relationships over and over again. Many of us wanted or even tried to end our lives. The stories I tell in the book are taken from my own work as a psychiatrist but have been extensively altered and merged to create people who are true to life, but not ‘real’ case histories. However my own story is very real indeed. It wouldn’t have been appropriate to have been so open when I was still practising- when people came to see me the focus was rightly on their problems not mine. When I was unwell I withdrew from seeing patients until I was recovered. I’ve never tried to hide my illness from colleagues. I’ve just never been quite so public about it.

So far, I’ve had some interesting reactions. As I mentioned above, I’ve been described as brave by some, but others are still clearly unsure what to say to me. When I’ve talked in the past about treatment, in particular the fact that I’ve taken antidepressants now for the last 20 years, I’ve certainly picked up from some of my colleagues that ‘this isn’t the sort of thing one talks about’. Why not? Isn’t this exactly what mental health professionals talk about every day? How can we challenge stigma in society if we cannot face up to our own tendency to stigmatise both our colleagues and, even now, our patients?

I have listened to junior members of staff describe people with depression who are not actively suicidal, or psychotic as the ‘worried well’. I’ve been told that depression is not a ‘severe’ mental illness warranting more investment of psychiatric and mental health nursing resources. I’ve read articles written by my colleagues, which describe it as ‘medicalising misery’. Only people who have never experienced the pain, despair and hopelessness could talk about depression in such terms. I’ve spent my life challenging such attitudes. I made it as far as being a Professor of Psychiatry, despite repeated episodes of depression. I know I’ve had better treatment than many people ever receive and my aim has always been to improve access to, and quality of care for depression. I’ve managed to live with depression and found ways of coping with it- though that has been far from easy. That is also what my book is about. I refuse to be ashamed of it.

Nobody should be.

My book, ‘The Other Side of Silence: A Psychiatrist’s Memoir of Depression’ is published this week by Summersdale.

Nothing like the common cold

Everyone disapproves of stigma, and yet that doesn’t seem to have had an impact on the way in which mental health professional themselves continue to stigmatize those with mental health problems. At this point I can hear all the professionals reading this saying ‘but I don’t do that,’ and indeed you (singular) may not. Yet those of us within the professions who have been mentally ill have experienced it. Mental illness is still something that happens to other people, but not to people like us.

A good friend of mine, Maureen Deacon, died this spring. She had been a Professor of Mental Health before taking her retirement, and I first met her more than thirty years ago when she was the ward sister in the Professorial Unit at Withington Hospital in Manchester and I was a Senior Registrar in the ward downstairs from hers. We had several friends in common and kept in touch over the years. I also knew her partner very well. In the early 1990’s Maureen persuaded me to recklessly join her on an overland bus journey from Manchester Piccadilly to Leningrad as it then was, which took 4 days in each direction. I remember someone getting on and asking if it was the Blackpool bus, and we all shouted ‘No, Leningrad’ to the interloper’s complete bemusement. You bond with someone when you both eat nothing but hummus and pitta: the only food you have brought with you for the journey, day in, day out. We hadn’t seen so much of each other in the last few years but we continued to meet every now and then for dinner and chat with our respective partners and to see each others’ feline companions.

Maureen had been unwell with cancer for some time. I wasn’t able to attend her funeral because I was in Orkney then, but I know she wanted everyone to dress in bright colours for her farewell, and not come in black. She was always very upbeat, hard-working, utterly reliable and a great friend. I also knew she had been depressed, both before and after her diagnosis with cancer. She never said much about it, but we talked briefly on occasions about what it felt like and taking antidepressants. She knew I had been unwell on occasions too. So it was a shock for me to read in the paper she completed just before her death, and published this month in the Journal of Psychiatric and Mental Health Nursing, that she had experienced six episodes of depression, and had seriously considered suicide during at least one of these. I’m ashamed I never picked up how bad things had been for her, but as she said in this personal account of her experience ‘I was an expert at hiding it.’

She wrote :‘being depressed is worse than having advanced cancer’ and at that time she had a life-limiting illness. She was acutely aware of the stigma that depression carries. This, she said, had two aspects. The self-stigma that is experienced by those of us who get depressed:

“…I tend to see my mood disorder as a character flaw-evidence of my weak and neurotic nature. Currently this is reinforced (for me) by the interest in mental health and resilience, clearly something I’m missing, in some sense at least. Secondly there is the guilt and worthlessness hat comes along for me with depression experience: ‘I should not feel like this I have a blessed life, a partner who loves me, a lovely home…’”

 

But also the stigma that depression carries, perhaps more so than ever, within mental health services in the UK. Even severe depression is not deemed to be serious enough for mental health nurses, working with Community Mental Health Teams, to be involved in the care of, except if the person is suicidal- and even then only for a limited amount of time. Depression, Maureen said, has been called one of the ‘coughs and colds of psychiatry’ and I’ve called out junior doctors for referring to anyone not under the care of mental health services who is anxious or depressed as the ‘worried well’. This kind of language doesn’t help the mental health professional in their company, quietly keeping their own counsel or indeed anyone with depression to feel any better about themselves. Diminishing their experience does not speed their recovery and discourages them from seeking help. When I was well such attitudes made me angry, but when I was unwell it certainly deterred me for a long time from publicly admitting I had any problems at all.

During my time as a consultant I saw and treated many nurses with mental health problems- students, mental health nurses, general nurses, ward sisters. After the case of Beverely Allitt, the nurse who murdered several children in a paediatric ward, I remember trying to help a seriously depressed young woman who was petrified that having treatment for depression would mean she was thrown off the general nursing course. There seemed, from her point of view, to be very little distinction being made between having treatable mental illness and potential psychopathy by her course directors. This was her understanding, but I would not be surprised if she was right. I’ve met health service managers with similar difficulty in grasping what mental illness actually is, how it affects a person, and how a person who suffers from it is more at risk of harm from others than vice versa. I’ve also seen mental illness treated very differently from physical illness by some managers. I was asked for information about a ward sister who was an in-patient on my ward through the inter-organisational route, following conversations between hospital managers, which was a blatant attempt to breach my patient’s confidentiality. Would this have happened ifshe had been receiving care for a physical illness? When I personally made my first very tentative visit back to unit I was working on when I had been off sick with severe depression, I received a letter from the Personnel manager a couple of days later, saying ‘You looked well. I hope this means you are returning to work soon?’

As Maureen said in her paper:

‘the sheer terror of work colleagues knowing I was unwell was enough to get me moving. Ironically, on the two occasions I was persuaded to take sick leave, I got better much more quickly’.

Reading her account fills me both with admiration…and regret. How I wish we had been able to talk more about how she was feeling, but she didn’t feel able to, and I never picked up the cues.

I will always miss her quiet wisdom and common sense.

Her conclusion was that, to really understand stigma as mental health professionals we have to get away from thinking mental illness is something that happens to other people . Not to us who are always resilient, invulnerable, immune to stress, and as a result far too ashamed to admit when we experiencing something which I can assure you is far from having something like a common cold.

Reference

Deacon M. Personal Experience: being depressed in worse than having advanced cancer. Journal of Psychiatric and mental Health Nursing, 2015,22,457-459.

(Still) taking the tablets

Not so long ago, I asked my current doctor how he thought I would have been over the last 20 years if I hadn’t stayed on antidepressants continually. He said he thought I would have had at the least a period of in-patient care. When I asked my other half, who has known me for nearly 30 years, and remembers life before and after I had medication his response was simple.

‘You would be dead.’

Since I last somewhat reluctantly shared my views on antidepressant medication a year ago, (before that I’d kept my head below the parapet) there has been a continuing debate about them both on twitter, where I’m quite active, and in the media. My blog was paired with an article written by a fellow psychiatrist who has very different views from my own, who told the Daily Mail she wouldn’t take antidepressants even if she were suicidal. I was pleased our contrasting views went out together. Others have questioned me directly with comments such as ‘I can understand why you take them if they’ve helped you, but why do psychiatrists still prescribe them when they don’t work?’ and a little more personally: ‘well you would say they help because you’re a psychiatrist.

When I joined twitter, I expected there would be primarily a view that medication was unhelpful and shouldn’t be prescribed. I guess that’s because that’s the message that the media often seems to prefer. There are several eminent mental health professionals who share this view and write about it frequently. Many of them are involved in the Council for Evidence Based Psychiatry and are active on social media. In fact, what I found, as well as people who share their views, was a substantial section of people who were willingly to talk of how medication has helped them. Some of them, like me, have also had psychological therapies, but many others have unfortunately not been able to access them.

NICE (the National Institute for Health and Clinical Excellence) is about to start a new review of the evidence, but its current advice is that antidepressants should not be used in milder depression, should be offered as option in moderate depression, and should be used in addition to psychological therapy in severe depression. That’s why I prescribed them when I was still practicing and most other psychiatrists and GPs, still do. But unfortunately the difficulty in accessing psychological therapy makes it hard in practice to follow the NICE guidance as we should. Many people do not get offered evidence-based treatment. If this happened in cancer it would be a national scandal, yet untreated depression, as we know too well, not only causes great suffering but can also be lethal. There are people who wouldn’t benefit from antidepressants who end up on them unnecessarily and only experience the side effects. There are others who feel there is no other choice open to them without a long wait. In severe depression, treatment which doesn’t also include psychological therapy is incomplete. Medication alone is never the solution.

I’ve stayed on tablets because, as my doctor and husband agree, I don’t think I could have managed to live the life that I’ve been fortunate to have, if at all. It’s been a productive one, but it hasn’t been easy. I’ve still had relapses: I was unwell earlier this year again and am now recovering. I didn’t cope with work stress well at all, although latterly Cognitive Behaviour Therapy helped me to find new ways to manage that; and I know that I still react badly to loss events. I have a family history of mental illness, and one first degree relative was hospitalized. My early life almost certainly contributed to my susceptibility. I’ve written at much greater length about this in my memoir, which will be published this autumn. However I haven’t been as low or completely unable to function as I was prior to taking medication. Psychotherapy helped me earlier in my life, but couldn’t prevent me having more severe episodes in my mid-thirties. Each time I’ve relapsed, my medication has been changed. Sometimes things have been added in. I’m on a combination now once more. I know there will be people who will say my recoveries are due to the placebo effect, which can be very powerful, but last time, as previously, I’ve begun to recover in the time scale predicted by the evidence. This time it was around 3 to 4 weeks. It certainly was not immediate, in fact as sometimes happens, my mood continued to deteriorate after I started the new treatment.

Medication has some truly vile side effects; I’ve experienced many of them and still do. I’ve had withdrawal symptoms too. Some people cannot tolerate them, and others feel much worse. Fluoxetine made me so agitated I had to stop it. In young people that effect can lead to increased self-harm. Medicines can help, but they can also be dangerous too. Its always about balancing the risks and potential benefits.

To suggest I would only say medication was helpful because I’m a psychiatrist devalues my experience as a service user. Perhaps it’s not easy to be seen as both at the same time. But I know others have found medication helpful too so I’m not alone. When writers suggest antidepressants shouldn’t be used, those of us who have benefited find that very scary. We know we are not weak because we need to take them, but sometimes it can feel like others honestly think this of us. All I am asking is that those who don’t want to take them respect the choice of those who do and continue to allow people who may possibly benefit (and have potential problems on them too) to make a fully informed choice. As I said previously I have never forced anyone to take them.

I have been suicidal, and I chose to start taking an antidepressant. At that point I was still sufficiently ambivalent about death to try anything that might help.

I’m still here.

Relapse and rewind

It’s fortunate that my other half and I share the same acerbic sense of humour.

‘When you aren’t well you start to talk all the time, and about 80% of it is rubbish, ’ he told me, ‘and you’re doing that now.’

It was at this point that I was finally able to admit that my mood, up and down since last autumn, had taken a major nosedive since New Year. The problem is that when I’m going down, I don’t generally recognise it until quite late, and I’m not always willing to listen to advice to ‘slow down’. This time, along with the usual symptoms of depression I’m so familiar with, I experienced the worst constant physical symptoms of anxiety I have ever felt; resulting in panic when I lost my bearing in Manchester’s Arndale Centre and I couldn’t immediately find the way out. This time, nothing would relieve the anxiety apart from alcohol. What my other half was referring to was the emotional and verbal expression of my anxiety. The constant seeking of reassurance and ruminating out loud about life problems, in a way that probably drives those around me crazy too.

However given my history of recurrent depression, it’s no surprise really that I’ve had another relapse. I had hoped that since retirement I somehow wouldn’t experience the same stresses I used to. And I’d been pretty well for a couple of years at least. But I was wrong. Losing my animal companion and several major family and health stresses I won’t go into here were enough to tip the balance again. It was back.

It’s the beginning of March now. For a while I panicked when I simply switched on the desktop computer. Now I can write again. I burst into tears in the middle of my last blog but I forced myself to get it finished. I have this feeling that if I can’t write then somehow I couldn’t live. Maybe it isn’t right, but I kind of believe that. For the last couple of weeks I’ve gradually been feeling better and the constant anxiety is subsiding to its usual level. I don’t feel like something awful is going to happen imminently and I’ve stopped thinking about death (I was having passive thoughts that life wasn’t worth living again). I heard birdsong the other day as I walked up the garden path and I realised I hadn’t taken any notice of the birds in the garden or their choruses or the bulbs shooting up for…well I’m not sure; because depression creeps up insidiously.

Why is my mood lifting?

Perhaps it just would do anyway. Spring is on the way. I’m bound to feel better…except for me it doesn’t happen that way. Even after the events that precipitate it are all past, my downturn goes on and on, thought not as low or for as long as when I was off medication altogether.

I can only make sense of it as a combination of the following and as you might expect from me, it’s a biopsychsocial combination of remedies:

  • I found a way to talk about my worries and fears about the future with my partner. It wasn’t easy but we managed to resolve some practical things I was concerned about.
  • I was able to utilise some of the practical coping skills for managing my rumination I learned from cognitive therapy and I started to use the guided mindfulness CD I had always been ‘too busy’ to listen to. I tried to stop myself from fighting against my mood, and simply accept that I was feeling terrible: bleak sad and empty. Paradoxically once I do that, I’ve learned, it is always a little easier to move forwards.
  • I forced myself to keep going out even though I wanted to shut myself in the house and never come out again. I’ve met many people in my career who have done just that. I had to ‘feel the fear and do it anyway.’
  • I was able, too with support, to put aside some of the impossible self-imposed deadlines I place on myself. I have to remember that my ‘Rules for Living’ are nigh impossible to live up to. Instead I set myself somewhat simpler goals like going out for a walk, and doing some washing. Small achievements which then helped me to move forwards.
  • I agreed to a change of medication. I wasn’t happy about it. I’m now on multiple tablets for my various conditions, but at the point I was at, it was worth a try. I cannot bear the thought of being sedated by medication and fully understood all my patients who refused to take medication that numbed their thinking. My mind has to be clear but when I’m very low I can’t frame the words and sentences either. I try to get to somewhere in the middle. I just cannot do it without pharmaceutical aid.
  • I sought and accepted the support of friends, real life and on line.

My other half did his part by being there for me, as he always is, even if I am talking rubbish, and arriving home one evening with a present of Lindt chocolate bunnies. Chocolate has antidepressant properties too, I tell myself as I bite the head off one of them. He tells me he knows I am getting better because I’ve started to talk about it all in the past again now. I think I’m getting better too, but I wont really know until I can look back and recognise how much I’ve improved.

That’s the nature of the beast.

Taking the tablets

I’ve been putting off writing about this topic. Even though I know it is something I really should talk about. I’ve used the excuse of the failure of British Telecom to sort out my intermittent broadband connection, which can be real a problem living alone on an island. But I cannot avoid it any more. So I am going to say what I think about antidepressants.

In the spirit of presenters at the American Psychiatric Association currently taking place in New York, let me begin my presentation with a few disclosures, so that you are fully aware where I am coming from:

I am a psychiatrist.

I don’t practice now, I’ve retired, but throughout my entire professional life I prescribed antidepressants regularly.

 

I have spoken at meetings funded by pharmaceutical companies and they have funded a couple of small research projects for me over the last two decades.

Neither my talks, nor my research have been promotional. I’ve never been involved in any research trial of a medication. At meetings I’ve generally been the acceptable psychosocial meat in the biological sandwich- squashed between presenters talking about the latest research into the biology of depression, much of which I’ve had a great deal of difficulty really understanding, even as an academic.

Last, but not least, I’ve taken antidepressants for most of the last 25 years. I’ve been continuously on them for 20.

My treatment record reads a bit like a history of the pharmacology of depression- and the promotion of antidepressants. Tricyclics (dosulepin), SSRIs (paroxetine and fluoxetine), SNRIs (venlafaxine and duloxetine) and adjunctive therapy (Lithium) with some antipsychotics thrown in.

So those are my disclosures.

What can I say about the rights and wrongs of taking medication?

First of all, just that: It is neither right nor wrong. I number among my friends people who will not take medication, and others who do. I don’t try and impose my view on them. Neither do they try and do that to me. It’s a matter of personal choice. But I hope it’s a fully informed choice when you make it.

Secondly: I dislike a great deal of what is written in the press about medication, because it often diminishes my experience of both having personally benefited from it and of seeing many of my most severely depressed patients do so too. Suggestions I would be harmed by it (which I haven’t been, though I’ve certainly experienced a great many side effects and had to withdraw from Seroxat- so I know about withdrawal symptoms) have proved incorrect. Some of the items in the media of late diminish the whole experience of severe depression by telling me everything can be solved by my going out for a run (radio 4 today) or taking up gardening.

Thirdly: Just because I’ve taken medication it doesn’t mean I haven’t had episodes of depression, but they haven’t been as severe as they were before I went on it. They are certainly not ‘happy pills’. I wear black most of the time and my friends will tell you I am not known to be pathologically over-cheerful. My mood dips, usually in response to how I cope with life events, and when I’m on medication it rights itself a little faster, but at least it bounces back. It used to take a lot longer, and I would get much lower, when I wasn’t.

Fourthly: Even Skeptics will acknowledge there is some evidence for antidepressant medication in severe depression. My approach clinically was always to work through the advantages and disadvantages of particular treatments and add my own opinion. As an expert, my patients expected me to have one. But the choice was theirs. If they were severely depressed, I’d ask that they not completely dismiss medication as an option, but to hold it in reserve for a while. I would do all I could to help them with their preferred option first. But if that didn’t work could we re-evaluate the decision at a later date?

Fifthly: Medication has its risks as well as its benefits. There are no easy options when your mood is very low. Side effects can be awful, and there are situations in which antidepressants should be used with extreme caution. Especially in younger and older people. A combination of venlafaxine and lithium gave me a prolonged Q-T interval in my ECG, which in lay terms means I had a greater than average chance of dropping down dead. I recovered on it, but it had to be stopped.

Sixthly: there is no place for the use of medication alone. Most people get depressed because they have problems, and if they don’t have them before they get down, persistent depression will cause them. It’s difficult living with a person with chronically low mood. Our physical health suffers too. We cannot work.

Talking of one form or another is an essential accompaniment to medication; anything on the broad spectrum from an honest and open conversation with a GP who listens to you and provides continuity of care to a longer term psychological therapy to help deal with some of the issues which increased your vulnerability to depression in the first place. Whatever is most appropriate and needed at the time.

Lastly: If the life events and problems which originally contributed to your depression have not resolved, you may benefit from staying on medication. Not everyone is able to make the changes in their lives that are needed to stay well. I’ve spent my life working in places where people lead very tough lives. There is nothing to be ashamed of in staying on medication, and I’ve argued the point with GPs who wanted to ‘wean’ patients off tablets prematurely. (Weaning is such a demeaning and unwarranted term anyway- it suggests a degree of infantilism).

I don’t know what would have happened if I hadn’t taken medication, but I can tell you things were not looking very positive. There are times when engaging in talking therapy is very difficult. When you feel as though there is a weight pressing down on your chest, making it very hard for you to breathe or carry on. The idea of going out for a run….well….need I say more? It feels impossible to be sure of your next breath. Antidepressants helped me to get to a point where I could use psychotherapy effectively. I’ve been able to keep going, write, research and hopefully help others. So I cannot put off honestly saying what I think and hope you will listen.

That’s all I can ask for.