Some musings

Writing in the BMJ back in 2007, Des Spence said ‘Medicine should admit that it’s offer to ‘cure’ depression was naive and wrong. Drug treatment should be reserved for the very few, not the many’. Twelve years on it seems we were not listening. In the last ten years antidepressants prescribing in the UK has doubled and, in a Mental Health Awareness week that would, given that increase, seem to have been unnecessary, professors at Oxford University have pledged once more to find the cure for mental illness.

Why then have we seen such an escalation in antidepressant prescribing?

Of course one explanation might be that the country is more unhappy than it was a decade ago. Despite the fact that the UK now ranks 15th in the World Happiness Index, it’s highest position since the measurements began, with its highest ever World Happiness Index Score, living in the UK has undoubtedly become harder. The BBC recently reported that UN Special Rapporteur, Prof Philip Alston, has described poverty in the UK currently as ‘systematic’ and ‘tragic’ with 14 million people in the UK living in poverty and 1.5 million people experiencing destitution. Furthermore he accuses the DWP of the ‘systematic immiseration of the British population’.

This has certainly translated into more people visiting their doctor with low mood. But to explain the increased prescribing of antidepressants on this is to acknowledge that we have come to believe that understandable unhappiness can be resolved by pharmacological treatment. No doubt much unhappiness has resulted from these and other social factors but do we really believe that the answer to such unhappiness is found in a pill? Sadly the answer to that question appears to be ‘Yes’.

We doctors, not without some reason, are all too fond of the quotation ‘Please don’t confuse your Google search with my medical degree’. But equally we would do well to acknowledge that our medical degrees are not to be confused with something that is sufficient to fully understand the personal experience of those who consult us.

Too many in medicine have lost sight that we are more than biological organisms. This is perhaps not surprising as we live in a reductionist world where everything is explainable by the purely tangible with the result that we our reduced to nothing more than biochemical automaton. Sadness then is seen as sickness, not just by doctors, but by society itself. Of course the media fuels much of this. Society has changed and now believes happiness is a right. For years doctors were, sometimes justifiably, criticised for acting as if they were God – now it seems that society demands that doctors fulfil that role and meet its every need. Patients are sent to us by teachers, employees, health visitors and other family members all with the belief that the patient needs tablets in order to restore the happiness that we have come to believe is normal.

But sadness is normal too. Please don’t misunderstand. To say someone’s emotional distress is a normal and understandable response to circumstances rather than due to illness is not to diminish the extreme pain of that distress or to imply that the person needs to simply get over it and pull themselves together. People who suffer like this are not stupid, lazy or pathetic. Far from it. It is simply that, for all of us, life sometimes is more than we can bear. In a world where we are constantly urged to be awesome, to be ordinary can sometimes feel like failure. It is not. I for one am slowly learning to be content with being ordinary.

Not only is sadness normal, it also has purpose. As Des Spence wrote back in 2007, ‘Depressive pain has a psychological purpose in the same way that physical pain has physiological purpose. Low mood is as normal and as important to our sense of well being as happiness is.’ Interestingly of course we are seeing an epidemic of opiate prescribing suggesting that we have become as intolerant to pain as we have to an unhappiness. Prescribing antidepressants without attempting to address the cause of the unhappiness is as foolish as giving painkillers for a broken leg without any attempt to fix the fracture.

We have forgotten too that sadness and difficulty can be good for us. In his book ‘Lament for a Son’, Nicolas Wolterstorff wrote ‘I shall look at the world through tears. Perhaps I shall see things that dry-eyed I could not see’. And Marcel Proust in his ‘In Search of Lost Time’ comments that ‘We do not receive wisdom, we must discover it for ourselves after a journey through the wilderness which no one can make for us, which no one can spare us, for our wisdom is the point of view from which we come at last to regard the world’

In my practice, the cause of a persons distress is generally at least partly explainable within a few minutes of talking. It’s lovely then to tell folk that they’re not as ‘mad’ as they thought they were – that in fact they’re not ‘mad’ at all. With patients now, when talking about antidepressants, I liken them to strong analgesics – they may have the potential to numb pain a little in the short term but they fix nothing, have nasty side effects, risk dependency and, as is increasingly being recognised, cause significant withdrawal effects that can make stopping them very difficult.

Another problem is that the supposed chemical imbalance theory, a theory increasingly under fire, is convenient for the state. A year of antidepressants only costs about a tenner whilst delivering talking therapies costs far more. Those services are already unable to cope with demand and patients on the NHS often have to wait over a year to see somebody for psychological support.

But the cost of bringing about the real social change that would address the causes of emotional distress and reduce the number who experienced significant adverse childhood experiences would be far more financially costly. None the less this is where governments should concentrate their efforts rather than lazily cough up for dubious pharmacological solutions. What’s needed fast is the healing of our broken society which leads to so much emotional distress – together with an acknowledgment that, even in the healthiest of societies, sadness is normal and inevitable and love and support needs to be provided by friends and family rather than being outsourced to professionals in the misguided belief that sadness equals illness.

But the increase in antidepressant prescribing is not solely the result of life being more difficult. It is also a consequence that we are less tolerant of the sadness we do experience.

“What Orwell feared were those who would ban books. What Huxley feared was that there would be no reason to ban a book, for there would be no one who wanted to read one. Orwell feared those who would deprive us of information. Huxley feared those who would give us so much that we would be reduced to passivity and egoism. Orwell feared that the truth would be concealed from us. Huxley feared the truth would be drowned in a sea of irrelevance. Orwell feared we would become a captive culture. Huxley feared we would become a trivial culture.”

So wrote Neil Postman in his book ‘Amusing ourselves to death’. Entertainment has become the opium of the people so much so that we can not tolerate unhappiness.So fundamental to our nature has the pursuit of happiness become that its absence is deemed pathological and something for which a cure must be found. And so we have pills that seek to make us happy so we can die amused – that is without a thought – regarding the reasons of our unhappiness. Huxley, who predicted there would come a time when a pharmacological method existed that would make people ‘love their servitude’ certainly knew a thing or two.

Last week I saw Arthur Miller’s play ‘All My Sons’. It devastatingly charts the collapse of a family as the lies, secrets and greed needed to maintain the American Dream are exposed. Surely there are parallels for us today where the dream is that life should be nothing but fun. The gambling industry has a lot to answer for, not least for it’s recent advertising tag line which attempts to suggest it’s a responsible organisation that only wants to be one of life’s many entertainments offering enjoyment to those who indulge in having a flutter. But with ‘When the fun stops, stop’ they are in fact adding to the clamour that that is what life is all about. By suggesting that where fun is absent from our lives we should immediately look to find something else to amuse us is to suggest that life should be nothing but happiness. The dream that we can live anaesthetised to every pain – physical end emotional – is one we must wake up from lest we continue to live a lie. Insisting that those who persist in being unhappy are ill is wrong. To paraphrase Jenna Coleman’s line in last weeks episode of ‘Victoria’ (I know – sorry!) ‘Madness is a label given by powerful people to those who behave in inconvenient ways.’

And this is where the medical profession needs to acknowledge its own part in the over use of antidepressants, a practice every bit as concerning as the overuse of antibiotics. Though for the most part out of a desire to help as best we can, we have colluded with patients that medication can take away their pain. Furthermore, in the misguided belief that medicine has the answer to all our patients problems, those who have had the audacity to refuse to benefit from the pharmacological solutions they are offered for their supposed illness, rather than being accepted as those for whom medicine does not have an answer, are all too readily labelled as psychological ill. What’s more, those who react to the antidepressants they are given or suffer withdrawal effects from their cessation are too readily seen to confirm the psychological illness with which we labelled them. Interacting with those who have suffered at our hands is humbling. We owe them the courtesy of listening to them and an acknowledgment that we were wrong. We need to be sorry.

That said it is not all the fault of GPs. We have been misled to believe in the merits of antidepressants by a pharmacological industry who has reported exaggerated benefits and minimised side effects. The pressure of workload that requires us to see more patients than it is accepted is safe means that there is little time to spend with patients to uncover the causes of their emotional distress or follow them up adequately. And even when the time is taken to determine the cause, and talking therapies are deemed to be the way to go, counselling services are not resourced sufficiently to provide the support that is required.

Though not excuses, these are all factors for why doctors themselves are at least partly responsible for antidepressant prescribing increasing so dramatically. We need to be professional enough to acknowledge the truth and seek to bring about change, not only within our consulting rooms but also on a local and national level. We need to stop believing that science and medicine can solve all our problems. Medicine needs to acknowledge its limitations but equally society must accept that limitation and not constantly demand solutions that medicine can’t give.

Des Spence’s words 12 years ago are just as relevant today. We should have listened then – we must listen now. Antidepressants are over prescribed and should be used not as a first port of call but only as a last resort, and even then with extreme caution.

Evidence suggests giving somebody a label of mental illness makes them more likely to be treated pharmacologically but that they will fare less well. Furthermore being labelled as mentally ill can worsen the isolation such people experience as someone who is deemed to be unhappy because of circumstances generally garners sympathy and support whilst those seen as mentally ill can come to be seem as less predictable, less approachable and less able to be helped by simple kindness and understanding.

What then is the answer? For some it’ll be an encouragement for science to go further to find solutions to the problems we currently can not solve. For others it’ll be to accept that they are more than their physical make up and cause them to look elsewhere for something they can hope in. And for others, like me, who are grateful for all that medicine has to offer but hopes in something more than mere science, it’ll be both.

So when the fun stops, as someday it surely will, let’s take a moment and, in that rare moment of stillness ask, ‘Is there more to life than merely having fun?’ And then, rather than stopping until the next shot of fun is provided, carry on, content to sometimes do without amusement and experience life as it really is.