Depression
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7402.1324 (Published 12 June 2003) Cite this as: BMJ 2003;326:1324All rapid responses
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Sir,
Mike Shooter's open account of his depression rang many bells. I
suffered my first major depressive episode in 2001. For some months I was
aware of increasing difficulties at work and of becoming less productive
both clinically and academically. However I attributed these to stress and
interpersonal and service-related issues. I contemplated changing jobs and
how to achieve a much-needed break from work - "What accident or injury
can I cause myself that will give me a couple of months off but not leave
me with lasting damage or impairments?". Eventually I went to talk to our
Royal College Regional Advisor about career changes and service
frustrations. After a few pertinent questions she said " Andy, you do
realise you're depressed and probably shouldn't be there" and arranged an
urgent appointment with my General Practitioner for the following day.
My GP prescribed antidepressants and tried to arrange some Cognitive
Behavioural Therapy. This was not readily locally available within the NHS
but a local non-NHS hospital had a well-established service, partially
funded by the NHS, for ill health professionals. He referred me there for
treatment. I slowly improved and returned to work after seven months,
initially part-time becoming full-time after three months.
Two months later my health authority withdrew all NHS funding to that
service. My CBT stopped and my consultant tried to broker my care back to
an NHS colleague. I relapsed and was again off work for a further two
months.
Thankfully I have been back at work for nine months and probably
fully recovered for the last three months. I have been well supported by
family, colleagues, employers, and by those treating me. Nonetheless I
have questions: why was I (and others) so slow to recognise my illness and
so quick to attribute everything to environmental factors?; why is an
effective treatment (CBT) only available after a long wait when the length
of an untreated depressive illnesses is associated with greater chronicity
and poorer outcomes?; should ongoing treatments to be stopped by
individuals or organisations with no direct clinical contact?; should the
NHS fund more speedy treatment for its employees or should NHS treatments
be good enough for its employees? - commercial organisations provide
private healthcare both as an incentive to recruitment and retention and
in order to minimise the disruption illness can cause to their core
business - my period of impairment lasted over two years with significant
costs to my patients, my Trust and my University.
Competing interests:
None declared
Competing interests: No competing interests
When doctors need to go beyond medicine
Mike Shooter’s narrative is remarkable for the fact that as a patient
he developed his own form of cognitive behaviour therapy. His approach to
his own illness is worthy of comment since implicit in his account is a
recognition of the shortcomings of the medical model of major depression
and, I submit, of other diagnoses as well.
In the US and in the UK, advocates for the mentally ill have had the
removal of stigma as a major goal. To this end, they have emphasized the
role of genetics and biochemistry in the genesis of the experiences that
lead to the diagnoses of interest. “Chemistry, not character” says one of
their posters. The hope is that seeing depression, manic-depression, and
other conditions as brain disorders and not as reflections on the
sufferer’s personal makeup will alleviate shame and societal disapproval.
As one advocate put it, “depression is something you have, not something
you are.” In this context, it is noteworthy that Dr. Shooter says “I have
to challenge the assumptions I make. And for me, this way of dealing with
it is extremely beneficial.” The assumptions he makes—that suggests a
third way of thinking about depression and manic-depression, not as
something we are and not as something we have, but as something we do. The
benefits of such an outlook have not been well-explored, but deserve to
be.
I have written elsewhere (1) about the time I was picked up by police
late at night wandering on the beach in my underwear thinking I was Elijah
the prophet, looking for evidence of the coming of the Messiah. My sense
of this incident, now nine years past, was that it was the most profound
and meaningful healing experience imaginable. At the time, I had never
felt more sane. I was aware of the apprehension of others as I said and
did odd things, but had a sense of meaning and purpose in what I was
doing. I was hospitalised under the assumption that something was
medically wrong with me; the medical model, however, was not only
unhelpful; it was detrimental. Sometimes mania serves a purpose which,
falling under the Aristotelian category of final cause, cannot be captured
by medical paradigms which focus on material and efficient causes.
Biological models, in trying to remove stigma from certain conditions,
remove self-knowledge and moral agency from the picture. It is an
indictment of our culture that we consider it stigmatising to recognize
that sometimes madness can originate from and be driven by factors in the
subject’s personality and character. I have proposed at
http://members.aol.com/Annieokl/bipolar.index.html that other perspectives
are possible and reasonable. It is time to enlarge the frames of reference
within which we conduct our dialogues concerning mania and manic
depression.
Ed Whitney
1. Whitney E. Mania as Spiritual Emergency. Psychiatric Services 1998
Dec;49(12):1547-1548.
Obviously these views are my own and not those of my agency.
Competing interests:
None declared
Competing interests: No competing interests