Sometimes words are not enough to lift depression
'Although I'm blessed enough to have a roof over my head , I still feel like I'm living in hell."
This is part of a blog entry that well-known author Marian Keyes wrote recently. It was widely reported in the media, including on RTE radio's 'Morning Ireland' programme yesterday. She goes on to say: "I can't eat, I can't sleep, I can't write, I can't read, I can't talk to people. The worst thing is that I feel it will never end. I know a lot of people don't believe it but depression is an illness, but unlike say, a broken leg, you don't know when it'll end."
These bleak words starkly describe depressive illness, so incapacitating that physical functions cease; eating, reading, moving, washing, talking all seize-up in a state of almost frozen emotional and physical paralysis. In psychiatric jargon, this is called psychomotor retardation. For some, life itself may end when the emotional pain and hopelessness become too engulfing and no light is visible, no joy foreseen and no love apparent.
And this despair is reflected in the words of Elizabeth Wurtzel, author of 'Prozac Nation', when she writes: "A human being can survive almost anything, as long as she sees the end in sight. But depression is so insidious, and it compounds daily, that it's impossible to ever see the end. The fog is like a cage without a key."
Yet there is hope for those with depression -- the roll call of those who suffered with depression but, with treatment, overcame it to lead fulfilled and productive lives is an expansive one and should be remembered during the periods of darkness. These include Goldie Hawn, Mel B, Audrey Hepburn, Dustin Hoffman, psychiatrist and author Kay Redfield Jamison and the list goes on.
During periods of depression there is no hope, no belief that anything will improve, no faith in any treatment offered. Many refuse medication believing that it will be ineffective or, increasingly, that it will be harmful.
Regrettably, there is much misinformation in circulation about the dangers of antidepressants. The debate has become polarised between those who believe depression is a state of mind that arises from life problems, and should be managed with talking therapies, and those who believe it is an illness, for which antidepressants are required.
In some respects, both are correct and the problem arises because the same word, 'depression', is used to describe two different phenomena. One is a mood state that arises in response to life circumstances, which I will refer to as situational depression, while the second describes an illness that can arise spontaneously due to changes in brain chemistry that are independent of life events. This is often termed clinical depression or depressive illness. Formerly, these different emotional states were called reactive and endogenous depression. Interestingly, those who suffer with clinical depression rather than situational depression can distinguish the two mood states as being very different.
With one there is a total lack of joy, a feeling of flatness, an inability to respond to or to experience love. With the situational variety, the person can be distracted from their low mood and tearfulness, they can interact and react to their surroundings and be responsive to those in their lives.
Changes to the way depressive illness is diagnosed have resulted in the two being conflated -- with those who are unhappy due to life circumstances being misdiagnosed as having a clinical depression and receiving antidepressants. The appropriate criticism of the use of medication in these circumstances has caused many with clinical depression to refuse lifesaving antidepressants.
Those with depressive illness find it difficult to engage with talking therapies due to their physical inability to even concentrate, let alone act, on advice. Engaging in pleasurable activities is physically impossible as the whole psyche seems to shut down.
Indeed, therapists who attempt to carry out these therapies with those who are severely depressed will often speak of their clients as not being 'reachable' or emotionally accessible. Those who, when well, are capable and decisive become needy and indecisive.
For those with clinical depression effective treatments are available that may, at a later time, include various talking therapies. But for early improvement antidepressants are the best and often the only option.
"Noble deeds and hot baths are the best cures for depression," said Dodie Smith, novelist and author of '101 Dalmatians'. Well, she was wrong. Any more than noble deeds and hot baths are a treatment for thyroid disease, neither are they a treatment for depressive illness. Anybody who doubts this should read the honest blog of Keyes. I wish her the very best for a speedy recovery.
Patricia Casey is professor of psychiatry at UCD and consultant psychiatrist in the Mater Hospital, Dublin