Everyone is depressed these days-or, at the very least, knows someone who is depressed. Libraries of books have been published on the subject, ranging from hard-core science through alternative therapies and self-help manuals. But why has depression become such a standard of mental health, when only a generation ago it was scarcely talked about? What has created this sudden increase in the disease? Is it a disease at all, or is it an illness? Or is it just a self-indulgence for the rich and bored?
Current wisdom is that depression is caused by a scarcity of one of two chemical neuro-transmitters in the brain: serotonin or norepinephrine. A person not suffering from depression has more than enough neuro-transmitters to go around. Excess serotonin and norepinephrine are re-absorbed, to be used again. In depressed brains, where neuro-transmitters are in scarce supply, anti-depressants are used to prevent the re-uptake of these neuro-transmitters back into the brain. (Think of water in the desert: if you can prevent the water sinking into the ground, more is available to be used.) With the action of anti-depressants on neuro-transmitters, depression is alleviated and we can all live happily ever after. It's a simple story; what's more, it seems to work.
However, there are other stories. Mianserin was a very effective anti-depressant, used in the 1970s and 1980s. It inhibited neither norepinephrine nor serotonin. But it worked well. Then there is cocaine which, every bit as efficiently as anti-depressants, blocks re-uptake of neuro-transmitters, but has no anti-depressant effects. Then there is the puzzling fact that the actions of both the neuro-transmitters and their receptors are altered by anti-depressants within an hour of taking the drugs; yet it takes up to ten weeks for any effects to appear.
A further problem with depression is that the only way to have it is to say that you have it. If you have a cold, people can hear you cough and sneeze; you have a virus in your system. If you have tuberculosis, the tubercule bacteria is visible under a microscope and lesions in the affected area show up on X-rays. You have both symptoms and the disease. But with depression the symptoms are the illness. You cannot be depressed and have no symptoms.
But the very essence of depression-the lack of pleasure in life, the despair which each day brings-no one except the sufferer can measure. Two measuring scales are used by doctors, but both rely on the patient's reported emotion. So the fact that depression seems to be hugely on the increase is not based so much on doctors telling their patients that they are depressed but, to a great extent, patients telling their doctors that they are depressed. A factor which has contributed to the rise in reported cases is that, with the development of anti-psychotic and anti-depressant drugs in the second half of the 20th century, you no longer risk being carted off to an asylum if you tell your doctor how you feel. Anti-depressants turned depressive people into out-patients rather than asylum dwellers. They also turned depression into a disease.
Most lay people want drugs for their self-diagnosed illnesses-and they want to self-medicate. They want to alleviate symptoms, manage pain, moderate their feelings. They are less interested in cures than doctors and drug companies are. Before the 20th century, when most medicine did little to help diseases and all drugs were sold over the counter, alleviation was the accepted notion-Carter's little liver pills, laudanum, 'Green Mountain Vegetable Ointment' (said to prevent ague, "swelled breasts," bronchitis, sore throat, ringworm, burns, shingles, erysipelas and piles). When specific drugs were discovered to cure specific diseases, diagnosis became all-important. Medicine was taken away from the patient.
The medical model of disease has just one successful outcome-cure. Prozac, saviour of tens of thousands of tortured souls, was hailed as the ultimate cure for depression. But what if depression is not a disease at all? Disease is an attack on organic matter, its only outcomes are a cure or death; illness, on the other hand, is the malfunctioning of various parts of our anatomy which can be managed more or less comfortably-such as diabetes, or asthma. Depression became a disease with a cure rather than an illness.
But anti-depressants don't seem to be a cure at all. They relieve the symptoms of depression in 70 per cent of all patients-a good result. But that is all: they alleviate the symptoms, they do not cure, just as insulin does not cure diabetes. Depression is normally self-limiting: after between six months to two years it generally lifts of its own accord, for reasons unknown. If anti-depressants are stopped before the depression has gone, the symptoms return. Equally, in cases of mild depression 40 per cent of patients respond as well to a placebo as they do to anti-depressants. This is not to say that the illness is imaginary. There are many illnesses which respond well to placebos: heart problems, ulcers, asthma-anything made worse by anxiety. This makes sense. Illnesses-even contagious ones-do not function in isolation. Some people catch colds easily; yet their partners, with whom they share everything, do not. Why? A combination of factors would probably include genetic inheritance, general health, environment and state of mind.
Maybe our highly medicalised way of handling depression has made the illness seem worse than it is, and also more prevalent. If we return to the pre-anti-depressant way of thinking, and simply accept depression as an illness in the way we accept asthma or colds; if we then self-medicate to ameliorate the symptoms, judging our own doses, using a combination of anti-depressants, therapy (which can be as successful as anti-depressants), acupuncture, or bungee-jumping-any remedy which works for the sufferer-would we feel better? We would certainly feel more in control. And according to the latest evidence, being in control plays an big part in determining whether or not we become depressed. Those who control their environments seem to get depressed less frequently than those who are in environments which control them. The rich and successful, whose clinic visits are so well publicised, are far less likely to be affected by depression than those at the lower end of the economic scale, who live and work in surroundings which are less pleasant and offer far less autonomy.
The most important redoubt in the battle for control is for the patient to have as much information as possible. The hundreds of books on depression can help. Every need is catered for, from the hard clinical exploration of David Healy in The Antidepressant Era (Harvard University Press), through books written by those who have suffered from depression and want to try to convey what it was like for them. Writers such as Philip Roth and William Styron have described their own descent into depression. Lewis Wolpert, in Malignant Sadness: The Anatomy of Depression (Faber) now joins them. The internet is another fountain of material.
The last decade has shown us what patients educated in their illnesses can do. Aids sufferers on clinical trials have led the way in vesting the power of treatment with patients. Here was an educated, literate group of people with a high degree of solidarity, who refused to allow the drug companies and the medical elite to control their lives. They insisted on meetings with drug companies and researchers to discuss drug programmes and how the drugs trials should be run.
This way forward is actually a way back-back to an earlier mode of dealing with illness. Today, drug companies and doctors define and sustain "depression." Instead of accepting their definitions, and asking doctors to cure us, let us instead take the management of illnesses into our own hands again. With alternative therapies, self-diagnosis, and (up to a point) self-prescription, we can reject the passive role thrust on us by the discovery of cures. We can create a new model of treatment for depression, this illness with no objective symptoms-and a cure with no explanation. We can accept that some things have no cure, but with careful management can be improved-or at least made bearable, for the duration.
