The devil is not as black as he is painted - Dante Aligheri
The number of anti-depressants being prescribed have doubled in the last decade. It seems fairly clear to me that the number of patients suffering from depression hasn’t risen exponentially in this time. The media portrays doctors as over-diagnosing and over-medicating this group of patients. I can’t argue with this because I know it happens.
What I also know is that there are no neat boxes which these patients either do or don’t fit in to. Asking them a series of questions based on the ICD-10 classification of depression is not going to make the scenario in front of us black and white. Depression is a lot more complex than a tick box exercise and what an individual scores on the depression scale will vary day to day. Our moods inextricably linked to our environment and those around us.
A 30 year old single Mum with 5 children in a 2 bedroom flat comes to see me. She sleeps on 2 chairs pulled together in the front room, one of her ex-partners gave her address when he was released from prison so he sleeps, tagged, on the living room floor. Her Mum died when she was a teenager and she helped care for her. Her Dad struggled with addiction problems and she hasn’t seen him since her Mum died, she was placed into care. She suffered abuse at the hands of a former partner and lives her life in fear. Crying, desperate and wondering what the future holds for her and her children.
A 54 year old man handing me the rope which had been tied in a noose around his neck 2 hours earlier. He had walked out of work, turned his phone off. He couldn’t ‘pretend anymore’, feeling lost and hopeless. Going through the motions daily, going through the motions of what he felt was expected of him, what people looking in on the outside thought his life looked like. Living his life for appearances only. Not living his life at all.
A 20 year old who took an overdose of paracetamol, sober in the planning, inebriated in the moment. She had an argument with her boyfriend of 6 months the week before, they split up and despite calling him hourly he had not returned her calls. She felt she couldn’t live without him, she amounted to nothing if he wasn’t by her side, she had no value amongst her peers and felt empty. She wasn’t sure she wanted to die. She just wasn’t sure this was how she wanted to live either.
A 72 year old man diagnosed with Parkinson’s disease. Aware his body was changing, not responding to the signals he was giving it, letting him down. He felt his future was lost. His wife woke up to find a note from her spouse of 50 years. He was gone.
A 47 year old man, married with 2 children, financially secure and doing the job he dreamed of as a child. He feels embarrassed, life is everything he always wanted. Yet he feels he has lost his way, is lacking purpose. Feeling increasingly anxious, unable to sleep, all enjoyment lost. Wanting to run away from everything he worked so hard to achieve, run away from all the things he once dreamed for.
A 17 year old struggling with exam stress and pressure, wanting to go to university but scared this is unattainable. Struggling with the pressure she is putting on herself. Struggling with the expectations of her family. Struggling to be the ‘clever one’. Struggling to keep up appearances to make everyone proud. Struggling to speak freely.
A 38 year old who was born the wrong gender. Living as a man trapped in a woman’s body. Living as a man trapped in a woman’s body recently diagnosed with breast cancer. Wondering if once cancer-free, the cruellest hand of fate means hormone therapy won’t be an option for gender reassignment. Testosterone converts to oestrogen. The breast cancer is oestrogen receptor positive.
Who is depressed? All of them, none of them, some of them? You decide. There may be tears, lack of eye contact, monosyllabic answers, avoidance, anger. It may be the passing comment as they leave. The repeated presentation for minor self-limiting illnesses, requesting of sick notes, the presentation of being tired all the time. A patient rarely sits in front of you and tells it how it is, how I’ve written in. This takes some probing. Some time.
On average I see 4 presentations of mental health difficulties a day, I work with 6 other doctors. On a duty day several patients present in crisis. This is every day. We can all do the maths.
So yes we probably do over-diagnose and over-treat patients. Questioning the current model of mental health leads to angry accusations that we are being dismissive. Trying to veer back to the naturally-intuitive behaviourist model of mental health is tricky when it has been practically shut down. The modern approach being that of treating the neurotransmitter ‘imbalance’, which we are told medication alone can correct. A financial goldmine for Big Pharma who are the prime advocates, and aggressors, for this model. Is this raw financial interest on their part or is this model of care progressive?
The human mind and psyche is an incredible thing. How we think, remember, process; the subconscious and the conscious. The tricks our mind plays on us when you stop and think are incredible, incredible and complex: deja-vu, hallucinations, thought broadcasting, functional pain, phantom pain. The list is endless. No single one of us is the same. Depression and mental health disorders aren’t tangible. So why then are treatment plans, the concrete therapeutic mind-set ‘a pill for every ill’.
I feel that there is little evidence to support the current biological neurotransmitter model. The complexity of life can’t be dismissed and diminished by a mere mix of crude chemical reactions. We need to move away from this and see the person, listen to the unspoken words, develop joint strategies and shift the paradigm back into a more behaviourist model.
Of course I am writing this to make you all stop and think. Who is Dante’s devil in all this? I would suggest it us, the doctors, we are not anywhere near as black as the media likes to paint us.