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Mental Health

Moody folk
If you get depressed and want to know why you may have to think
again about cause and effect, suggests Trevor Turner.

We live in the theoretical shadow of Sigmund Freud. So we tend to assume that what happened in our childhoods is a sufficient explanation for our personalities and lifestyles, and – extending this notion – that if a happened before b then a must have caused b. But this is astrological thinking, and common diseases that come and go naturally, or have a psychiatric rather than physical basis, get misunderstood thereby.

For example, you send a researcher round to ask a depressed woman what has happened to her in the previous six months. She tells you her husband left her, the cat died and she does not like the neighbourhood. But depressive illness often exasperates partners, neglects pets and alienates the neighbours. What was cause? What was effect?

It seems obvious – but is it reasonable? – to blame social predicaments for the increased rates of depression among working-class women. Constant poverty, inadequate amenities – you know they are depressing. But transfer this model to Vietnam in the 1960s or Somalia in the 1990s and there’s a quandary. Put simply, why have not most Vietnamese and Somalis got so depressed as to commit suicide?

The problem is that we do not really know why some people get depressed and some do not. By analogy, we can understand why there were Poll Tax riots in London in 1990, but often over the last 15 years it has been more difficult to understand why those masses living in down-at-heel housing estates in inner London did not regularly march on Buckingham Palace and burn it down. Were they too depressed, perhaps?

Getting mad at the Poll Tax, London, 1990: but the depressed don't get even - or march on Buckingham Palace.

Oddly enough, one Freudian explanation would be that, actually and perversely, we select environments to reflect our inner states of being. In other words, social classes or social chaos are generated by an unconscious wish fulfilment. Our desire to be ‘normal’, and the intense stigma attached to psychiatric illness (whether termed ‘nerves’, ‘neuroses’, ‘madness’ or whatever) may lie in our realization, within ourselves, of these connections.

Let us consider how this might work. The poorest and most wretched of the earth are homeless psychotics. There is clear evidence for a ‘drift’ as opposed to a ‘shift’ hypothesis; for the finding that schizophrenia is much more common, proportionally, in the lowest social classes. If you study the fathers of 100 people with schizophrenia, they will show a normal variation across all the classes. Yet their offspring tend to cluster heavily at the bottom of the pile, having ‘drifted’ down the scale. Given the symptoms of schizophrenia, the difficulties in thinking coherently, the social withdrawal, the impaired concentration and initiative, this is not surprising. And remember that about a quarter of those with schizophrenia – perhaps more – do not even get officially diagnosed. They just hide out in the ‘lower depths’ (as Mikhail Gorky put it), dependent, unemployed and semi-vagrant. In other words, schizophrenic illness creates an under-class.

When we move further ‘up’ the scale, to the ‘official’ working classes, things become more subtle. Members of this group tend to smoke and drink much more, and have higher rates of depression than those ‘above’ them.

Depression is, however, too broad a concept. Feeling tired more often than not, feeling bad about yourself, experiencing stress rather than ease, having an eyes-down, furrowed-brow attitude to things, these are the chronic states of mind that keep you in your place economically.

Take a more unusual group, the manic depressives. Smart manics – provided they do not go over the top – tend to be creative, dynamic and personally successful. They storm along through all the difficulties and life-events, thinking relentlessly positive thoughts. In their more monstrous form they appear as Robert Maxwell or Margaret Thatcher, accumulating money or power or both. In their more subtle form they tend to inhabit – surprise, surprise – the upper-middle classes. Many great artists, scientists and politicians have families rich in distinctly ‘moody’ folk, traits that often protect them from unemployment and other social disruptions.

Even though malnutrition, disrupted childhoods and environmental pollution create disabilities, they mainly magnify the differences: the anxious worry more; the depressed drink more; the psychotics mutter more meaninglessly; the manics make more millions. Class and mental illness walk hand-in-hand.

The World Health Organization defines health as ‘the absence of ill-health’. So is mental normality just feeling, er, okay? Societies of ordinary people, rather than famous egomaniacs, should probably be our aim. Perhaps we must all learn a bit about psychiatry at school – take a step on the road away from moral judgements of behaviour, away from religious systems that get locked into good versus evil, towards an empathy with people’s vulnerabilities, so as to start teaching children how to find out if things are true and what makes minds work.

Dr Trevor Turner is Consultant Psychiatrist at City and Hackney Community Services NHS Trust, London, England.

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