Saturday 20 December 2014

Defining depression: Illness or existential problem?

Those who suffer from depression say they constantly come up against a brick wall when trying to explain their condition to others so how can this increasingly common ailment be separated from simple sadness?

Daniel and Majella O'Donnell
Daniel and Majella O'Donnell

MAJELLA O'Donnell, the wife of the famous Irish singer Daniel, has given a full and frank interview with Gay Byrne on RTE 1. She spoke openly about her coping with cancer, for which she raised thousands of pounds for research when she was first diagnosed. Thankfully she is now disease free.

She also bravely described having to cope with depression. She recounted how it began after the birth of her second son when she realised there were serious marital problems for her to deal with. She said that even now she was still taking antidepressants, but that, from time to time, she experienced periods of low mood. She opined that dealing with cancer was "a piece of cake" compared to having to face depression.

The very serious challenge of dealing with depression is something many patients articulate to me. Like Majella, my patients describe it using words like "a black hole", "an unseen weight on my shoulders", "a feeling of detachment from everything and everybody I care about", "a feeling of being without emotion, just emptiness". Many are unable to cry despite wanting to burst out of the state of utter emotional blankness they feel. Most are pleased when they do eventually succumb to tearfulness.

But it doesn't end there and this of itself is not a treatment, but only a brief reprieve of a few hours at most.

The problem, my patients tell me, is nobody sees anything physically abnormal and, even if they do notice an expression of blankness or loss of weight, the advice offered is to get out and enjoy life. If only it were so easy! The person is torn between total disinterest and physical inability to do what others advise, against their own self determination to improve things.

A further complication is that the despair-filled thoughts of life's meaningless, without hope, leads some of religious orientation to seek help from God. Their focus is on self-scrutiny and prayer. In other words, this illness is misconstrued as a spiritual rather than a medical matter. The inevitable failure to find any relief from their suffering leads to even greater self-criticism and self-loathing.

Sometimes depression can occur without any explanation or trigger while, for others, it can be preceded by a stressful event such as job loss, a broken relationship, a death. However, the low mood and sadness do not disappear even when the triggering event is long gone; the symptoms persist: insomnia, reduced appetite and weight loss, impaired concentration, overwhelming panic and so on. This IS depressive illness.

All of this deters many of those with depression from seeking treatment, either because they believe they should be able to overcome it through their own actions or because it has been falsely attributed to life stressors or to unresolved spiritual issues.

However, not all low mood that follows from a stressful event is a depressive illness.

And this is where the journalist and author John Waters caused controversy by suggesting that "depression" didn't exist, in so far as the term was applied to his own response to a number of recent events. In fact, the world of psychiatric practice that I inhabit is increasingly faced with what are two seeming contradictions: the failure of many to seek treatment for depression when it is an illness, and the large numbers referred to us who describe low mood using the word "depression" in the context of sadness, unhappiness and the depressive effect of alcohol.

The linguistic problem is that depression, the illness, refers to the profound and immovable feelings of "depression". That same word describes unhappiness, sadness at the vagaries of life coupled with the existential uncertainty that befalls many. So how do we decide when an event occurs in a person's life, whether they are unhappy at what has occurred or whether they have tipped into the illness of depression?

These are difficult but important distinctions since the illness is often a recurring one which requires continuing interventions and possibly antidepressants in the long term.

On the other hand, the low mood of unhappiness or spiritual doubting, require assistances that are outside the medical sphere. In the absence of biological markers to help us distinguish one from the other, we are frustratingly dependent on the symptoms the person describes, their persistence even when the stressful situation has resolved and on the extent to which day to day living is impacted.

Both Majella O'Donnell and John Waters have addressed the "depression" issue from two very different angles – one, the illness, the other, the existential. It's a pity that the one word is used to describe both very different phenomena.

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