Depression is not a universal condition – we need a more nuanced approach to mental health | Sidney bloch
NOTNot a week goes by without a public figure (Naomi Osaka being the most recent) revealing her battle with depression. The frequency of these disclosures should come as no surprise given the pervasiveness of feelings of sadness.
So why paint depression as a puzzle? One way to untangle this question is to tell the stories of six randomly selected (completely anonymized) patients that I have treated in my psychiatric practice, some of them with the help of colleagues.
Kate * asked for my help in overcoming her writer’s block; her doctoral thesis was overdue. The intense distress this caused was made worse by the fact that her boyfriend constantly berated her for “not taking care of it.”
Jane, an occupational therapist, was referred by her supervisor after she was discovered “lying” about her devouring grief for her parents, both of whom died in a car accident.
I was asked to assess Amy who was struggling to bond with her first baby three weeks after birth. Her feeling of sinking as a mother had become a source of relentless agony.
Jennie, a 70-year-old widow, had lost so much weight that her specialist doctor suspected cancer. However, a battery of tests did not reveal any physical condition. Although mostly silent, she whispered intermittently that she deserved to die after committing “so many sins.”
Abdi, 18, was devastated by the deaths of many other asylum seekers who drowned after their rickety boat capsized. Charged with unbearable guilt, he could not accept his “failure” to save even one person.
Finally, a middle-aged professional who recently returned from a conference abroad was unable to overcome the intractable jet lag and weariness compounded by severe bronchitis. He felt completely defeated and helpless.
In all six patients, it was clearly clear that their mood had dropped. Colloquially, they suffered from “depression”. But let me show you how they differed fundamentally in terms of the treatment required. A single approach was clearly inapplicable.
Back to Kate and her writer’s block. Having gained an appreciation for his plight, I recommended that we explore, in a safe place, what might hinder him. It soon became apparent that she had no recollection of ever having received affection from her father, for whom the only thing that mattered in life was material success. He grew up in a poor home and through determination he became a wealthy businessman. Kate soon realized that her ambitious academic pursuit was not only an ill-conceived and futile pursuit, but also not in keeping with what she “genuinely” valued – a loving family in which her hoped-for children would thrive. .
Jane’s mock mourning was understandable within minutes of our first meeting. She had indeed suffered a loss. Her brother Edward, whom she had always been close to, had died of leukemia at the age of 10 after four years of suffering. For more than a decade, Jane’s parents and her two siblings had avoided their painful loss. Jane had felt deeply lonely as a teenager and resented the idea that the family had erased Edward’s name from their history. She and the family (the latter reluctantly) agreed to meet with me to find out how “everyone could help in the situation.” Five sessions were enough for them to openly share their grief and regain their original warmth and closeness.
Amy’s descent into a dark abyss was typical of a syndrome not uncommon in obstetric practice, namely postnatal depression. Yes, depression, but under the special circumstances of her new role as a mother. The reassurance, encouragement, the opportunity to share feelings with other mothers suffering from the same pain, and the antidepressant medication, while being cared for in a mother-baby unit, all helped to make Amy more confident and safer to relate to her “adorable chickpea”.
A fellow doctor, baffled by Jennie’s severe weight loss and bewildered by her silence, asked me for my opinion on her mental state. The account provided by her two daughters allowed me to understand the nature of Jennie’s illness. They said their mother had been pining for her late husband since his death two years earlier. The bereavement had taken on a malignant form, escalating into a typical “delayed depression” which, along with his poor physical condition, made electroconvulsive therapy (ECT), administered cautiously and safely, the treatment of choice. And that’s how it turned out. A six-treatment course over two weeks helped Jennie achieve a remarkable recovery. She was able to reestablish loving relationships with family and friends and remember her “wonderful marriage”.
Like Jennie, Abdi was consumed with a deep sense of loss. His internment in a detention center after the tragedy at sea only caused more pain. Authorities urged us to administer antidepressants, pointedly reflecting the need to see them do “something.” The idea that a pill could fix her pervasive misery was easy, to say the least. Our recommendation could not have been more explicit. Since Abdi’s mental state would undoubtedly worsen during his stay in detention, it was essential, we argued, that he be returned to the care of his sister and family who had lived happily ever after. Australia for several years. Fortunately, their plea to the Ministry of the Interior was heard, paving the way for a program of empathetic and supportive “social therapy”.
I know the sixth patient all too well. His wife urgently sought help from a psychiatrist friend who immediately offered unconditional support to the whole family as well as a prescription for antidepressant medication (and an antibiotic for relentless bronchitis). He was convinced that improvement would follow once the drugs kicked in. His prediction was correct. The patient recovered both physically and psychologically within a few weeks.
That patient was me! Although I have never had such a horrible experience, I have learned that I am extremely sensitive to the effects of jet lag and that I should be very careful on my future trips.
Two crucial lessons flow from my involvement with all six patients (and dozens more over four decades of psychiatric practice).
First, a person with mood disorders is unique – in terms of clinical history, life circumstances, and worldview. As Maimonides, the illustrious 12th-century physician, points out: “Consider first and foremost the person and only then the symptoms. And that should always be the case with what we colloquially call depression.
You don’t get depression like it’s a virus. On the contrary, we feel downcast in a particular context. The role of a mental health professional is therefore to respond with empathy and in partnership with a patient by seeking to understand why he or she is currently presenting a problem. this clinical picture.
Only then can the required treatment be designed. The six patients discussed clearly show this. Each of them needed an individualized program tailored to their distinct set of problems and concerns: family therapy; combined psychological, social and pharmacological treatments in a mother-child unit; long-term individual therapy; medication and support or ECT.
A second lesson is inextricably linked to the first: Mental health professionals have an ethical obligation to keep abreast of scientific advances in their field. Consensus guidelines tell us not only about the usefulness of a specific treatment, but also how best to apply it. We can then make an informed judgment about what is in the best interests of their patients.
The concept of depression has always been so ill-defined that it doesn’t make sense, especially since the Covid-19 pandemic is raging around us. The risk prevails that more and more people facing the vicissitudes it imposes will be inappropriately labeled and prescribed antidepressants.
We would be wise to take a more nuanced position encompassing a range of clinical scenarios, each pointing to a specific set of interventions to achieve the best possible outcome for a vulnerable person.
I felt safe knowing that my psychiatrist was fully aware of its benefits and risks.
Sidney Bloch is Emeritus Professor of Psychiatry at the University of Melbourne. He is the former editor of the Australian and New Zealand Journal of Psychiatry and author of 15 books, including Understanding Troubled Minds.
In Australia, support is available from Beyond Blue on 1300 22 4636, Lifeline on 13 11 14 and from MensLine on 1300 789 978. In the UK, the Mind charity is available on 0300 123 3393 and Childline at 0800 1111. In the United States, Mental Health America is available at 800-273-8255
* Names have been changed to protect identities