Nnot a week goes by that a public figure (Naomi Osaka is the most recent) doesn’t reveal their battle with depression. The frequency of these revelations should come as no surprise, given the ubiquity of feelings of sadness.
So why portray depression as a mystery? One way to unravel this is by telling the stories of six randomly selected patients (thoroughly anonymized) whom I have treated in my psychiatric practice, some with the help of colleagues.
Kate* sought my help to overcome her writer’s block; her dissertation was much too late. The intense suffering it caused was compounded by her boyfriend who constantly admonished her to “don’t deal with it”.
Jane, an occupational therapist, was referred by her supervisor after she was caught “lying” about her overriding grief for her parents, who had both been killed in a car accident.
I was asked to review Amy who was struggling three weeks after birth to bond with her first baby. Her sense of perishing as a mother had become a source of unrelenting pain.
Jennie, a widow in her 70s, had lost so much weight that her medical specialist suspected cancer. However, a series of tests did not reveal any physical condition. Though largely mute, she occasionally muttered that she deserved to die after committing “so many sins.”
Abdi, 18, was struck by the deaths of many fellow asylum seekers who drowned after their rickety boat capsized. Loaded with unbearable guilt, he couldn’t come to terms with his “failure” to save even one person.
Finally, a middle-aged professional who had recently returned from a foreign conference was unable to overcome a persistent jet lag and fatigue, exacerbated by severe bronchitis. He felt utterly defeated and helpless.
It was obvious in all six patients that their mood had fallen sharply. Popularly, they suffered from ‘depression’. But let me show you how they differed fundamentally in the treatment they needed. A one-size-fits-all approach was clearly not applicable.
Let’s return to Kate and her writer’s block. After understanding her plight, I recommended that I investigate in a safe place what might be hindering her. It soon became apparent that she could not remember ever receiving affection from her father, for whom the only thing that mattered in life was material success. He grew up in an impoverished house and through sheer determination he became a wealthy businessman. Kate soon realized that her ambitious academic pursuit was not only an ill-thought-out, futile quest, but also inconsistent with what her “authentic” self-esteem — a loving family in which her hoped-for children would flourish.
Jane’s feigned loss was understandable within minutes of our first meeting. She had indeed suffered a loss. Her brother Edward, with whom she had always been close, had died of leukemia at the age of 10 after suffering four years. For more than a decade, Jane’s parents and two siblings had avoided their heavy loss. As a teenager, Jane had felt deeply alone and outraged that, the way 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 find out how “could help anyone in the situation”. Five sessions were enough for them to openly share their grief and regain their original warmth and closeness.
Amy’s descent into a dark abyss was typical of a not uncommon syndrome encountered in obstetrics practice, namely postpartum 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 who are suffering in the same way, and antidepressants while being cared for in a mother-baby unit all contributed to Amy becoming more confident and confident in her dealings with her. “cute chickpea”.
A fellow doctor, stunned by Jennie’s severe weight loss and baffled by her mutism, asked my opinion on her mental state. The story of her two daughters enabled me to understand the nature of Jennie’s illness. They talked about their mother’s incessant longing for her late husband since his death two years earlier. Grief had taken on a malignant shape and escalated into a typical “retarded depression,” which, combined with her precarious physical condition, made electroconvulsive therapy (ECT), administered gently and safely, the treatment of choice. And so it turned out. A course of six treatments over two weeks helped Jennie make a remarkable recovery. She was able to restore loving relationships with family and friends and reminisce about her “beautiful marriage”.
Like Jennie, Abdi was consumed with a deep sense of loss. His internment in a detention center after the tragedy at sea only brought more grief. The authorities urged us to administer antidepressants, ostensibly as a result of the need to be seen doing ‘something’. The idea that a pill could cure his ubiquitous woes was completely easy to say the least. Our recommendation could not have been more explicit. Since Abdi’s mental condition would undoubtedly deteriorate while he remained in detention, it was essential, we argued, that he be left in the care of his sister and her family, who had lived happily in Australia for many years. Their plea to the Department of the Interior was happily followed, paving the way for a program of supportive, empathetic “social therapy.”
I know the sixth patient all too well. His wife urgently sought help from a psychiatrist friend who immediately offered unconditional support to the entire family and prescribed antidepressants (and an antibiotic for the relentless bronchitis). He was convinced that there would be an improvement once the drugs were used. His prediction was correct. The patient recovered both physically and psychologically within a few weeks.
That patient was me! Although I had never experienced such a horrific experience before, I learned that I was extremely sensitive to the effects of jet lag and that I should be very careful when traveling in the future.
Two crucial lessons arise from my involvement with the six patients (and with dozens of others during four decades of psychiatric practice).
First, a person who presents with a disturbed mood is unique – in terms of clinical history, living conditions and world view. As Maimonides, the illustrious 12th-century physician, emphasizes, “Consider the person first and then the symptoms.” And so it should always be with what we popularly call depression.
We don’t catch depression like it’s a virus. On the contrary, we feel depressed in a certain context. A mental health professional therefore has the role of responding empathically to, and cooperating with, a patient in trying to understand why he or she is currently presenting with this clinical picture.
Only then can the necessary treatment be devised. All six patients discussed clearly demonstrate this. Each needed an individualized program tailored to their specific set of problems and concerns: family therapy; combined psychological, social and pharmacological treatments in a mother-baby unit; long-term individual therapy; medication and counseling or ECT.
A second lesson is inseparable from the first: mental health professionals are ethically obligated to keep abreast of scientific advances in their fields. Consensually agreed guidelines inform us not only about the usefulness of a specific treatment, but also how it can best be applied. We can then make an informed judgment about what is in the best interest of their patients.
The concept of depression has always been so ill-defined that it’s pointless, and even more so now that the Covid-19 pandemic is raging around us. There is a risk that more and more people, confronted with the perils that it entails, will be labeled and wrongly prescribed antidepressants.
We would be wise to take a more nuanced view encompassing a spectrum of clinical scenarios, each pointing to a specific set of interventions to achieve the best possible outcome for a vulnerable individual.
I felt safe in the knowledge that my psychiatrist was fully aware of its benefits and risks.
Sidney Bloch is Professor Emeritus of Psychiatry at the University of Melbourne. He is the former editor of the Australian and New Zealand Journal of Psychiatry and author of 15 books, including Understanding Troubled Minds
In Australia, support is available from Beyond Blue on 1300 22 4636, Lifeline on 13 11 14 and 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 at 800-273-8255
* Names have been changed to protect identities