Not a week goes by that a public figure (Naomi Osaka is the most recent) doesn’t disclose their battle with depression. The frequency of these revelations should occasion no surprise given the ubiquity of feelings of sadness.
So, why depict depression as a conundrum? One way to unravel this matter is by telling the stories of six randomly selected patients (thoroughly de-identified) I have treated in my psychiatric practice, some of them with the help of colleagues.
Kate* sought my help to overcome her writer’s block; her PhD thesis was way overdue. The intense distress it provoked was compounded by her boyfriend constantly admonishing her for “not getting on with it”.
Jane, an occupational therapist, was referred by her supervisor after she had been discovered “lying” about her all-consuming grief for her parents, who had both died in a car crash.
I was asked to assess Amy who was struggling to bond with her first baby three weeks after the birth. Her sense of foundering as a mother had become a source of unremitting agony.
Jennie, a widow in her 70s, had lost so much weight that her medical specialist suspected cancer. A battery of tests however revealed no physical condition whatsoever. Although mostly mute, she murmured intermittently that she deserved to die after committing “so many sins”.
Abdi, 18, was devastated by the deaths of many fellow asylum seekers who had drowned after their rickety boat capsized. Laden with unbearable guilt, he could not come to terms with his “failure” to save even one person.
Finally, a middle-aged professional recently returned from an overseas conference could not surmount intractable jetlag and lassitude, made all the worse by severe bronchitis. He felt utterly defeated and helpless.
In all six patients, it was blatantly clear that their mood had plummeted. Colloquially, they were suffering from “depression”. But let me show you how they differed fundamentally in terms of the treatment they required. A one-size-fits-all approach was manifestly inapplicable.
Let’s return to Kate and her writer’s block. Having gained an appreciation of her plight, I recommended we explore, in a safe place, what might be impeding her. It soon emerged that she could not recall ever having received affection from her father, for whom the only thing that mattered in life was material success. He was raised in an impoverished home and by dint of sheer determination he became a wealthy businessman. Kate soon realised that her ambitious academic pursuit was not only an ill-conceived, futile quest but also not in accord with what her “authentic” self valued – a loving family in which her hoped-for children would flourish.
Jane’s feigned bereavement was understandable within minutes of our first encounter. She had indeed suffered a loss. Her brother Edward to whom she had always been close had died from leukaemia aged 10 after four years of suffering. For more than a decade, Jane’s parents and two siblings had avoided their grievous loss. Jane had felt profoundly alone as a teenager and resentful that, as she saw it, the family had erased Edward’s name from their history. She and the family (the latter reluctantly) agreed to meet with me to work out how “everyone could help in the situation”. Five sessions sufficed for them to share their grief openly and to recover their original warmth and closeness.
Amy’s descent into a dark abyss was typical of a not uncommon syndrome encountered in obstetric practice, namely postnatal depression. Yes, depression, but in the special circumstances of her new role as a mother. Reassurance, encouragement, an opportunity to share feelings with other mothers similarly afflicted, and antidepressant medication, while being cared for in a mother-baby unit, all contributed to Amy becoming more confident and secure in relating to her “adorable chickpea”.
A physician colleague, stumped by Jennie’s severe loss of weight and perplexed by her mutism, sought my opinion about her mental state. The account provided by her two daughters enabled me to understand the nature of Jennie’s malady. They told of their mother’s ceaseless pining for her late husband since his death two years earlier. Grief had assumed a malignant form, escalating into a typical “retarded depression”, which when coupled with her precarious physical condition made electroconvulsive therapy (ECT), administered cautiously and safely, the treatment of choice. And so it turned out. A course of six treatments over two weeks helped Jennie to make a remarkable recovery. She was able to re-establish affectionate relationships with family and friends and reminisce about her “wonderful marriage”.
Like Jennie, Abdi was consumed by a profound sense of loss. His internment in a detention centre after the tragedy at sea brought only more sorrow. The authorities pressed us to administer antidepressants, ostensibly reflecting a need for them to be seen to do “something”. The idea that a pill could mend his pervasive misery was utterly facile to say the least. Our recommendation could not have been more explicit. Since Abdi’s mental state would undoubtedly worsen while he remained in detention, it was essential, we argued, for him to be released to the care of his sister and her family who had lived happily in Australia for several years. Their plea to the Department of Home Affairs was fortunately heeded, paving the way for a program of supportive, empathic “social therapy”.
I know the sixth patient only too well. His wife urgently sought help from a psychiatrist friend who immediately offered unconditional support to the whole family as well as prescribing antidepressant medication (and an antibiotic for the relentless bronchitis). He was confident that improvement would ensue once the medications had kicked in. His prediction was spot on. The patient recovered both physically and psychologically within a few weeks.
That patient was me! Although I had not previously undergone such a ghastly experience, I got to learn that I was exquisitely sensitive to the effects of jetlag and would need to take great care when travelling in the future.
Two pivotal lessons arise from my involvement with the six patients (and with dozens of others over four decades of psychiatric practice).
First, a person presenting with disturbed mood is unique – in terms of clinical history, life circumstances and outlook on the world. As Maimonides, the illustrious 12th-century physician, stresses: “First and foremost, consider the person and only then the symptoms.” And so it should always be the case with what we colloquially call depression.
We don’t catch depression as if it were a virus. On the contrary, we feel downcast in a particular context. A mental health professional therefore has a role to respond empathically to, and in partnership with, a patient in seeking to understand why he or she presents currently with this clinical picture.
Only then can the requisite treatment be devised. All six patients discussed show this clearly. Each one of them needed an individualised program tailored to their distinct set of problems and concerns: family therapy; combined psychological, social, and pharmacological treatments in a mother-baby unit; long-term individual therapy; medication and support or ECT.
A second lesson is inextricably linked to the first – mental health professionals are ethically obliged to keep abreast of scientific advances in their field. Consensually agreed guidelines inform us not only of the utility of a specific treatment but also of how to best apply it. We can then make an informed judgement as to what is in their patients’ best interests.
The concept of depression has always been so ill-defined as to be meaningless, and even more so as the Covid-19 pandemic rages around us. The risk prevails that more and more people facing the vicissitudes it imposes will be affixed with the label and prescribed antidepressants inappropriately.
We would be wise to adopt a more nuanced position encompassing a spectrum of clinical scenarios, each pointing to a specific set of interventions to achieve the best possible outcome for a vulnerable person.
I felt secure in the knowledge that my psychiatrist was fully cognisant of its benefits and risks.
Sidney Bloch is an emeritus professor of psychiatry at the University of Melbourne. He is the former editor-in-chief of the Australian and New Zealand Journal of Psychiatry and author of 15 books, including Understanding Troubled Minds
In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, Mental Health America is available on 800-273-8255
* Names have been changed to protect identities