Thursday, 6 March 2008

The concrete broke your fall...

I've been following with interest the news stories over the past week which have reported the 'discovery' that Prozac and similar antidepressant drugs (SSRIs) "are no better than a placebo for mild to moderate depression". I speak as someone who has been on one of these drugs (not Prozac, but one of the 'family') on and off for several years now, mainly for a variety of depression-related things, and more recently for anxiety, so I have a vested interest in this story.

Since the news broke, it has been reported in some quarters that we knew all along that medication for depression was little better than "sugar pills", as the placebos are sometimes known; on the other hand, scores of doctors have been speaking out about the positive effect that the drugs have had on their patients.

The story fascinates me on all sorts of levels. Firstly, how is it that drugs companies are allowed to organise, conduct and if necessary hide the trials of their own products? I'm probably quite naive about how the medical industry works, but I had always assumed that drugs were not made available to the public until they had passed independent tests of safety and effectiveness, and until the details and results of those tests had been made available for all to see (or at least, for medical professionals to see). But now it seems that the trials are conducted by the very people who stand to make a huge profit if they are a success; furthermore, they can, if they wish, deny ever having conducted a trial if it doesn't work out how they'd like. Last Wednesday's Guardian carried an article by Ben Goldacre, a medical doctor, explaining some of the myriad ways in which drugs companies can make these trials say whatever they want (apparently there's more info at, but I didn't get that far).

In fact, another source (which I have now forgotten) reports that drugs only have to be shown to have passed 2 (I think - some small number anyway) independent trials; they can then be passed regardless of how many trials they've failed. Apparently drugs companies sometimes publish the results of the same trial in several different forms, thus making it look like a number of different trials have been passed. This is pretty appalling stuff, and no one seems to be about to do anything about it.

On the other hand, one assumes that GPs would not continue to prescribe particular drugs if they didn't see some evidence that they actually helped their patients to get better. This is part of the argument that has come forward for Prozac - the trial evidence may not be there, but people have taken it for years and it has made them feel better. But this of course brings us to the placebo effect. Is it really the drug that makes people feel better, or is there some other reason? Is it that they feel better simply because they take a pill and then expect to feel better? Would the depression have passed anyway? Is it the comfort of having a professional take their illness seriously?

This, for roughly the first time in the history of this blog, is where I speak with something which is doing a damn-near-passable imitation of authority. Depression is a horrible thing. It's much more than just 'feeling down' or 'having a bad spell'. In its most severe form, you wake up in the morning feeling like all hope has been sucked from your world; getting out of bed is an effort in itself; normal tasks can become nearly impossible - but worst of all is the feeling that this is never going to go away. Not a worry that it's never going to go away, but an absolute certainty that this is how life will be until you die. My depression is relatively mild (and also seasonal), so I don't feel quite this bad very often, but when I do I would try almost anything that claimed to work, no matter how wacky or bizarre - and maybe that desperation for treatments to work feeds into how I respond to them.

I have to say that I do generally feel better when I'm on antidepressant medication - barring, of course, the not-so-pleasant side-effects (particularly horrible is the way the drugs can make you feel emotionless – sometimes I wish I could just have a good cry). But when I get depressed, there is certainly something to be said for the feeling that I have gone to my GP and she has taken me seriously, and now I'm taking a tablet every morning - it's like I've inwardly signed a 'statement of intent', and now I have to get on with recovering - which sometimes motivates me to do other things, like exercise, and eating well, which are likely to improve my mood further. The thing is, when you're depressed, having someone just listening and taking you seriously has an incredible healing power in itself, and can give you enough of a boost to recover a little bit of hope that things will get better.

So maybe there is some kind of placebo effect, coming from the opening of a little window of hope which gives me the motivation to do things that will generally improve my health. In fact, exercise and good diet are probably better for you than any medication or therapy, but it's finding the energy to even care enough to do them that is the usual problem, and it may be that the drugs have their place in giving that much-needed boost.

I doubt very much, though, that in more severely depressed people, this brief boost is going to be enough to give them the longer term feeling of well-being that many Prozac users report.

This leads to other questions: how many people diagnosed with depression are really suffering from it? Can it be called depression if a sugar pill, a bit of care from a doctor, and looking after yourself better are enough to lift it? Is there any point in treating it; wouldn't it go away on its own? At what point do we draw the line between feeling 'a bit blue' and being clinically depressed? In clinical trials, what criteria are used to measure the 'level' of depression? (This is not in any way to suggest that those who are feeling 'a bit blue' rather than severely depressed are not in need of care and treatment; rather, that antidepressants may not be the most effective way to help such people.)

Depression is notoriously difficult to diagnose and measure; the symptoms can often be quite vague, and some are fairly common in the general population - the average list of 'signs of depression' will include things like 'trouble sleeping', 'aches and pains' and 'feeling less motivated than usual' - all of which can be caused by a rough few weeks at the office and maybe a few too many late nights. But give people access to the Internet and they have a ready-made source of things-that-might-be-wrong-with-them - "you know, I do have trouble sleeping", "I don't really feel like going out this Friday night" - individual interpretations will vary and it's hard for doctors to know what they're dealing with.

When you start to look for answers to these kinds of questions, you find that a lot of the time they just don't exist; there are a lot of 'maybe's and 'possibly's. A lot more research into mental health issues is needed before they are fully understood; likewise, a lot more research is needed into the effectiveness of various treatments.

The final thing that interests me, though, is this idea that where depression exists, it must be 'cured'. This may seem like an odd thing to say; of course, no one wants to live with depression – but what prompts my remark is that I think we need to look more closely at what depression actually is, and what purpose it serves, before we simply lump it in with 'illnesses' and concentrate on getting rid of it.

Depression is not a new thing, although levels of diagnosis have risen sharply in recent years. It has been around for as long as we have, and in fact many societies do not view it as a medical condition at all - the attitude that “it must be got rid of” is more prevalent in Western society than elsewhere. Perhaps this is not surprising; we tend to have a less holistic approach to medicine than many other parts of the world. In societies with a more holistic approach, depression sufferers are often treated with respect; they will be allowed time to process how they're feeling, to learn from it, and to work through it; they will be allowed to stand back from responsibility and be supported by others around them - and they may well come out stronger and wiser at the other end. The time of illness can be a learning experience, and a signpost to a better way of life, not just for the individual but for the whole society.

By contrast, in Western society (I use 'Western' in this sense to include societies such as Japan, where mental illness is considered shameful), an illness in one part of the body tends to be treated in isolation from whatever's going on elsewhere - it is seen as an inconvenience, to be got rid of as quickly as possible by taking a few tablets. It seems clear that we have lost sight of the connections between mind, body and soul which our ancestors took for granted. Pills may be found which mask the emotional symptoms, but in doing so they may hide the root cause - be it emotional, spiritual or physical. Well-meaning friends may push us to 'try to get out more', to 'shake it off', but in doing that, we can in fact miss out on much-needed time and space for reflection and renewal. But we should no more do this than we would take painkillers for a back injury and then go and play tennis – physical pain is there as a warning, telling us to rest body and muscles; likewise, emotional or mental pain is saying something similar about our need to take time out.

Where an increased proportion of people in a given society are suffering from depression, perhaps it's a warning sign that that society has got its priorities wrong; in the UK today we are working longer hours than ever, spending a lot of time travelling, trying to make ends meet with huge mortgages, finding it harder to spend time with friends... is it possible that increased depression levels are a warning sign that we need to slow down, make time for each other and reprioritise? Rather than treating depression as something to get rid of, would we do better to look at what it says about our society and see whether the root cause lies there? Could we learn from it? Would we serve depressed people better by letting them work through it, with appropriate, understanding support, rather than merely getting rid of their symptoms as quickly as we can, and throwing them straight back in at the deep end? I believe we would.

I believe this applies at the level of society, but also in individual friendships. It can be very tempting to try to make our friends feel better, and to get them back to 'normal'; but for me, the most supportive friends have been the ones who just went through the pain with me and let me feel it. But I'm brewing another post about this, so I'll leave it for now...

In some ways I've become thankful that I've suffered from depression. It has given me a much clearer insight into how my body works than I would otherwise have. It has taught me to respect my body and to treat it well. It has shown me connections between mind, body and soul. It has forced me to take time out and to slow down; to think about what really matters. It has prevented me from getting caught up in the 'Rat Race': for that, I am particularly grateful. It has forced me to see good things wherever I can; to take delight in the smallest of pleasures.

Of course, when this season of depression is over, as I hope it will be soon, I'll be glad to move on and excited to see what's next. In the meantime, though, I'm (reasonably) at peace with this chance to get to know myself.

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