MENTAL HEALTH Depression and addiction

The birth of the blues
Common sense tells us that depression overwhelms us when things go
wrong in our lives. But many psychiatrists and doctors believe depression
is caused by a chemical imbalance in our brains and that an antidepressant
drug can put it right. Keith Oatley surveys the evidence to discover
what really gives us the blues.

THE principle symptoms of depression are readily recognisable: persistently sad mood, lack of energy, recurrent thoughts of suicide, difficulty in concentrating and making decisions, feelings of self-reproach or failure, agitation, loss of appetite, loss of weight and insomnia. The depressed person may also become demanding, clinging, irritable or withdrawn from others.

Few depressed people have all these symptoms. But someone going to a doctor complaining of sadness along with two or more other symptoms would probably be diagnosed as suffering from depression. And because most doctors believe what they have been taught in medical school - that depression is largely due to biological imbalances in the brain - they are likely to prescribe one of the many anti-depressants on the market, particularly if some of the person’s symptoms are of a’physical’ kind, like weight loss, insomnia, loss of energy.

Anti-depressant drugs are designed to elevate mood. And for some of the people who take them, they provide a respite from severe states of torment.

But mental torment doesn’t mean mental illness. The patient is distressed, not mad.

In the last ten years or so a new approach to research on mental illness has been developed. Instead of waiting for patients to visit their doctor researchers visit ordinary people in the community,

One finding from this kind of community survey in different parts of the world is that surprisingly large numbers of people - particularly those who live in cities - are suffering quite disabling symptoms of depression.

One survey in a British inner city area involved 800 people. The results showed that in the month preceding the interview six per cent of the men and 15 per cent of women were suffering from depression and/or anxiety attacks severe enough for them to qualify as out-patients at a psychiatric hospital. These figures are confirmed by other surveys in Europe and the US.

Another consistent finding was that married women are twice as likely to be depressed as single women, whereas marriage for men decreases the risk of depression. Being working class (as opposed to middle class) also substantially increases the risk for both men and women, more than doubling the risk in some parts of Britain. And being unemployed more than doubles the chance of having severely distressing psychiatric symptoms.

The surveys on which such results are based are numerous and reliable. And figures showing that between 15 and 30 per cent of women in cities are suffering from psychiatrically diagnosable depression and anxiety is no small matter.

What these surveys reveal is a large reservoir of distress not seen by doctors, not recorded in statistics, perhaps not receiving any help at all.

But what the figures also throw into question is the idea that all these people are suffering from mental illness - something chemically wrong with their brains that could be put right by drugs. Could ‘mental illness’ be responsible for a condition which in women is made more than twice as likely through marriage? And which, in men, is made twice as likely through being single - and, for both sexes, is made substantially more likely by divorce, bereavement or separation?

In some 90 per cent of episodes of depression that occur with a relatively clear trigger point, people are not ‘mentally ill’ at all - they are just responding naturally to losses and difficulties in the course of ordinary life. In one survey I was connected with, for example, 30 per cent of men who had lost their jobs and remained unemployed for six months became depressed. There was no increase in levels of depression in a control sample of men who remained employed. Anti-depressants are certainly not going to reduce unemployment.

Depression is a kind of mourning for something lost. In Westem society bereavement is the main event expected to lead to the kind of sadness, withdrawal and discouragement that characterises depression. It has become clearer now that other losses are moumed too.

From listening to the stories that people tell about their lives, and carefully comparing the conditions under which people live, a difference emerges between the ordinary grief of a loss, and thoroughgoing depression. Depression occurs when not one thing but two occur: first a severe loss, and second, that there is no other source of hope, no altemative ways to experience oneself positively other than through the activity or the relationship which has been lost. There seems no visible way out. So, logically enough, the sufferer stays put. Then mouming becomes depression, a form of hopelessness, a discouraged giving-up.

This begins to explain why depression is a greater risk for women - especially married women - than for men; and why unemployment, social class and where one lives affect one’s chances of becoming depressed.

Having a happy, intimate relationship tums out to be one of the most important factors protecting people against depressive breakdowns: however sad one may be at a loss in some other area of one’s life, being valued and cared about as a lover or a spouse helps protect one from breakdown.

On average, women in Westem society tend to experience themselves in fewer kinds of activity than men. If a man’s child is a failure at school he may be disappointed as a father, but he is likely to have altemative ways of fulfilling himself, perhaps in work. But his wife, particularly if she cannot confide in her husband, may lack altematives - and this can spiral into the hopelessness that constitutes depression.

A 40-year old woman I interviewed, Mrs X, had been made redundant twice within 18 months from jobs where she was skilled and respected. The financial climate was unfavourable for her kind of work, yet she had to pay rent and, as a single parent, support two teenage boys. She had been divorced several years before, had friends but no important love relationship. Following her second job loss she broke down. Her doctor was helpful and kind, and had even arranged for a short spell in hospital when the drugs he prescribed did not seem to help her. When I saw her she was still very low, uncertain about the future and considering retraining for some less vulnerable occupation.

Ms X is not depressed because there is anything wrong with her mind. She is depressed because too many things have gone wrong in her life for her to cope on her own. Her needs are obvious - and utterly ‘normal’. Her depression is a healthy signal, a waming of needs crying out to be met. To suppress her symptoms with drugs, and to label her as ‘mentally ill’, would surely compound her problems rather than solve them.

Keith Oatley is a lecturer in psychology at Sussex University, UK