I was 21 when I had my first breakdown. I’d been suffering teenage depression on and off for six years but not known what it was, never questioned it. Suddenly I was too ill to go to lectures. In those days there was no specialist student health care, but a local GP (family doctor) had become increasingly concerned by the mental health problems he saw in his student patients. A year or two earlier he had decided to specialise in treating this epidemic. I was lucky enough to be referred to him by my own GP.

I don’t know what he prescribed me. Almost certainly a tricyclic antidepressant (this was autumn of 1970). I’ve just looked them up on the net and I certainly gained several recognised side effects: increased heart rate, drowsiness, blurred vision, dizziness, confusion. Mind you I was pretty confused when he first saw me.

The first consultation was weird. Okay so he sat behind a large desk and I had a traditional upright surgery chair. But he offered me a coffee, which was shrewd. It worked in much the same way as being given a drink when you arrive at a party. I had something to hold on to, something to take sips from as if I felt confident and purposeful.

His overall approach was way ahead of its time, perhaps because he had not been trained as a psychiatrist so came at the problem with fresh eyes. The starting point was medication, but he made it clear that the antidepressant was only to give me the opportunity to work hard at learning to cope with depression. So that’s what this was. Depression. Hmmm.

“The trouble is that when you feel down you have only the one escape route: running.”

I was a keen member of the university cross-country and athletics teams, and hell I enjoyed running. Best of all was ten or fifteen miles at relaxed pace through the beautiful countryside around Durham. That’s Durham England. If I felt a bit rough I went for a run. But if I felt seriously rough any attempt to run would be frustrating because the energy was gone. Clinical depression affects you physically. I would try to train and fail. The harder I worked at it the worse I got, which was absurd. Races were a waste of time.

“You try to escape by running and find that route is closed to you. What do you do? Nothing. You do nothing because you have no other escape routes set up apart from friends who are usually not available because they’re working or having a life of their own.”

I must have looked blank.

“When I get home from work I’m often feeling pretty rough. What do I do? I knock hell out of the garden. Do I like gardening? Sometimes. Not always. But I do it anyway, and it helps me feel better even when I don’t think I’m enjoying it. But some evenings it’s too dark or it’s raining heavily.”

What did he do then? Sorry, I can’t remember.

“Now you’re too depressed to run what other hobbies do you have?”

- I write.

“When was the last time you wrote?”

- well, er, I wrote a novel two years ago …

“Are you well enough to write?”

- er … well … I read a lot. I listen to music.

“You just told me you’re picking up books, trying to read them, and giving up after just a page or two. You said music isn’t doing anything for you anymore. In fact you have nothing but friends to fall back on when you’re this ill.”

I doubt I nodded, but he was right.

He told me I must find at least one new hobby. How? Well I could try browsing the local bookshop to see if anything caught my eye.

“This is your homework. You find one new activity to try. I don’t care what it is so long as you try it. No matter whether you find a new hobby first time off, the key thing is to try something. And then something else. And we keep going till you have a battery of escape routes to fall back on when you’re depressed. See you next week. Good luck.” He smiled and shook my hand firmly.

I went to the local bookshop (these days a Waterstones but not then). It was an Aladdin’s cave, but cold and dark and grey with the air like treacle. I kept wanting to cry but I made myself work through every single shelf of non-fiction. I read every title. I took some books off the shelf for a browse.

I have no idea what activity I picked, but I do remember the faint glimmer of light that doing something, anything, left me feeling ever so slightly better. No, I didn’t feel happy. No, I still couldn’t think straight. No, the future was still black. But something eased just a tiny bit, barely enough to notice. I had made a crucial discovery: when you’re depressed doing anything is better than just sitting around thinking about how bad you feel.

Actually there were two other long-term results: a lifelong love of browsing bookshops (which fortunately my wife shares, though it’s cost a lot of money over the years), and a tremendous variety of interests. To focus enough on writing to produce the next book for my agent to try and sell I’ve had to be brutal in sidelining many hobbies.

The doctor cum counsellor I saw in Durham from 1970 through 1972 used a range of techniques. The one I’ve described above would probably now be called solution-focused therapy. It was exactly what I needed at the time, and has benefited me ever since. I’ve sometimes used it with people I’ve tried to help, but rarely as forcefully as it was used on me: once I had a really bad weekend and made an appointment to see this doctor. What was I supposed to do when I realised I was getting worse? Anything but sit around moping. What had I done over the weekend? Sat around moping. There’s your answer so next weekend have stuff planned and do it no matter how you feel. Just do it. He then warned me that if I ever came back complaining of being worse yet had not followed this strategy then he’d not see me again. Hard words, but spoken forcefully at exactly the right time. The next weekend I had planned in detail, and I stuck with the plan. I didn’t feel okay. But I didn’t feel worse. Success! Often success for a depressive is entering a bad situation and simply not feeling worse than before.

If your counsellor proposes some action on your part then you have only two rational choices: you can give it a go, or you can stop seeing that therapist. And what harm is it going to do trying out their suggestion? After all, it might work. You’ll be sure it won’t, but give it a go. Give it a serious go, and in so far as you can when ill be open minded. Not every suggestion will work, but you can be almost certain that when you first hear of something that can help you’ll try to reject it; that is part of depression.

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I lived with a chronically depressed dad, and reading this helps me make sense of my childhood and understand both my parents better.

Jenny, my wife, has severe attacks of depression which have no obvious cause. I cope using a range of strategies I’m still learning, and because I love her very much. Anne Sheffield’s book has rejuvenated my efforts to help and support Jenny, and has provided a wealth of useful information. Despite forty years of study I found this book a revelation. Thank you Anne.

During the eighties Jenny became frighteningly depressed with occasional manic phases and a brief period of mild catatonia. Over six years she spent two and a quarter years in psychiatric hospital making no progress. Most of the doctors either ignored me or treated me as an irrelevant annoyance. After a couple of years I was at my wits end trying to support Jenny, cope with my own depression, and look after our two sons. Someone at the hospital arranged for me to see a psychiatric social worker who came across as tired and distracted – certainly over worked. I asked if there was any way we could be helped as a family. “Are you asking to have the children taken into council care?” he asked. “Hell no!” I said. “In that case there’s nothing we can do to help. Good bye.”

A nuclear bomb doesn’t just affect where it explodes. When I’m badly depressed there is fallout. Other people suffer and have to cope. I’m very fortunate to have known so many people prepared to live with my mood swings – not least Jenny and the boys (sorry guys, we know you’ve been men for a long time but we can’t help thinking of you as our ‘boys’).

If you live with someone who is depressed you know exactly what I’m talking about. The trouble is that most people around you do not understand, and this includes a frightening number of medics. The situation is improving. Medics are better trained now. People are beginning to understand. But having someone close to you depressed will never be easy.

Anne writes with knowledge based on experience of being depressed and living with depressed people. She includes many true examples from people she knows and has interviewed. I think every aspect of the situation is covered, and the result is an eminently readable book full of useful information, great coping strategies, and hope.

If you live outside the USA then you do need to allow for a natural bias towards the situation and culture in the States, but that should be no problem. Inevitably there are sections which are incomplete or slightly biased, but that doesn’t matter. My experiences living with Jenny when she is depressed bear little relation to the scenario described by Anne, which makes me feel extremely fortunate and blessed. There are forms of talking therapy Anne is not familiar with. But her writing has expanded my understanding and clarified a lot of stuff that was scattered and confused in my head. The book was first published in 1998 so a few parts are now slightly out of date.

The book is aimed at anyone who lives with a depressive or manic depressive (bipolar) person. It has sections specific to you if the depressed person is a parent or a child. It looks at the differences between male and female depression, between child (up to about 25) and adult depression, and between different types of depression. It looks at the range of treatments available, both chemical and non chemical. It does all this using simple language and considerable human warmth.

Anne has not just based the book on her own experiences and those of people she helps at the Mood Disorders Support Group in New York City. She’s also gone to a great deal of trouble researching the facts, and has had her writing checked by medical professionals.

If you live with a depressed person buy and read this book, and keep it to hand for reference and encouragement.

If you are depressed then get this book for the person closest to you, and when you’re feeling well enough try reading it yourself.

Anne Sheffield’s related web site is here.

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How can you treat depression?

This depends on the person, the type of depression, its severity, and its cause. Do not try to treat yourself. See someone who is medically trained and experienced. If you have clinical depression and they do not specialise in psychiatry they should refer you for treatment to someone who does.

The world is grey and it's always raining, but there's hope.

Treatment with medication

Severe depression needs medication first before the patient is likely to be able to cope with or respond to any kind of talking therapy. Some cases which feel like the end of the world but are less severe (such as atypical depression and the early stages of reactive depression) may well respond to the right talking therapy.

There is plenty of advice on the net about what medication to use. Be very, very wary of this. If it helps you understand the problems and how anti-depressants work that’s great. But you need someone medically qualified to diagnose the problem and identify the most likely medication to work. Even then you have to wait weeks, maybe a couple of months, to experience any effect. The dose may need to be adjusted. It may turn out the obvious treatment doesn’t actually work for you and something else needs to be tried. And then of course there are usually side effects. Almost all side effects are worth living with! Do not buy medicine over the net.

Since I was first diagnosed with depression in 1970 I’ve been prescribed a range of different medicines. Some had little or no effect and needed to be changed. One mood stabiliser made food taste like cardboard. Since throughout most of the five years I took it I was stabilised at a fairly depressed state I finally persuaded a psychiatrist I should come off it.

Warning: once you are taking any medicine for depression only reduce or stop taking it under competent medical supervision. Stopping too fast or at the wrong time can have devastating effects.

A previous article on medication for mental illness is here.

Treatment with talking

I’ve had a range of talking therapies (counselling, psychotherapy). Cognitive Behavioural Therapy (CBT) and Mindfulness Therapy have been very helpful. I also use some related stuff from Neuro-Linguistic Programming (NLP). At one stage eighteen months of psycho-dynamic therapy was highly effective. Don’t expect the therapist to do all the work, and don’t expect quick results. And by the way (note especially to Jeremy Laurance of The Independent) the old Freudian style psychoanalyst might ask you to lie down on a couch, but I doubt any other counsellor would. Also psychoanalysis seems to be unhelpful with depression.

Once clinically depressed talking therapies are unlikely to be of any help until the depression has been eased at least a bit with the right medication. If your therapist tells you medication is never needed for depression you need to find another therapist. They may be very good at what they do and mean well, but in this one statement they are dangerously wrong. Mild forms of depression can often be helped a lot by the right therapist using the right talking therapy well, but not so severe biological depression.

Two previous articles on counselling/psychotherapy for mental illness are here and here.

Treatment by other methods

I find it helpful to use light therapy. We noticed my depressive cycle is often related to time of year so bought a light box (the psychiatrist was cynical), and it works for me as part of an overall treatment plan. It should be used only in the mornings to avoid it causing sleep disturbances. I start using it on dull days well before autumn (fall) kicks in. My own light box uses fluorescent tubes. These need to be of the right type because ordinary fluorescenrt light does not contain the part of visible light I most need. Also after a year or two of use the specialist tubes wear out; they still provide plenty of light, but have lost the bit I need and I have to replace them. I haven’t tried the newer type of ‘blue’ light available. Light therapy is intended to help boost serotonin levels in people who from Seasonal Afferctive Disorder (SAD). A good introductory Wikipedia article is here. Skip the irrelevent bits.

In extreme cases of depression which do not appear to respond to medication a course of ECT may work. This involves the painless electrical stimulation of parts of the brain. I had it many years ago, and found it a perfectly acceptable form of treatment. I recovered from that depression fast as a result but later relapsed. For me a longer term treatment involving both medication and counselling was needed.

There are many ‘alternative therapies’ on offer. These include acupuncture, homeopathy, feng shui and aromatherapy. My own feeling is that these include a mixture of total junk with some stuff of value. I haven’t read up thoroughly on most of them. If you want to know more a Wikipedia article to start with is here.

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The article is informative and well written, but misses out in two areas. I’ll look at one today, the other tomorrow. This is by no means a complete analysis, but hopefully it will be of help.

All colour has been washed out of the world. It's raining all the time. Real life is just a blur.

What is depression?

Jeremy’s answer is a good introduction given the necessary brevity – it’s just a minor aside in an article focussed elsewhere.  Here are some additional thoughts from the point of view of a long-term sufferer married to a long-term sufferer:

Depression is not just feeling down for a few days. It is an illness, a change in brain chemistry which can have devastating effects on both the sufferer and on friends and relatives.

Phrases like ‘loss of pleasure in things that were once enjoyable’ is correct but misleading because it gives no sense of the seriousness of the problem. My own depression is controlled to some extent by Prozac, but I can still be knocked out of useful activity for days at a time.

It’s not just a matter of getting less enjoyment from watching my favourite TV programme. I feel weak, like you do the first day of recovery from flu. Often my body hurts, I get headaches and sinus pain. I sleep more hours a day, and on occasion have slept all day and all night.

If I can push myself to do anything I soon feel tired physically and mentally - no stamina. And it’s so hard to start an activity however simple because I can’t imagine enjoying doing anything but sleeping. Usually, with Prozac’s help, once I’m started on something I actually do enjoy it. The trouble is that in the motivation phase I have to take it on trust this will happen.

Taking photos on the North York Moors last weekend was enjoyable even though I was depressed. Some of the photos are here (or two posts down if you’re on the blog home page). Writing this article is hard because my mind is fuzzy and resists being made to think clearly. It’s the mental equivalent of trying to run through knee-deep porridge. And I’m not experiencing much pleasure in the process.

I also can become severely withdrawn and uncommunicative, snapping at Jenny if she tries to help. I can become over-critical of other people, and very short-tempered, very angry. Sometimes I’ll go for hours fighting the desire to cry without knowing exactly why. Anything that involves getting dressed, or leaving the house, or worst of all going out in the evening, feels almost intolerable. Something that works for me at my worst is to withdraw into playing computer games for several days. Sometimes I need to increase the dose of Prozac.

I’m not a typical depressive. I’m not sure anyone is. There are different types of depression and people are affected differently, but real clinical depression of any type can be catastrophic. At least until it is adequately treated. It has altered the course of my own life, although perhaps for the better. It has ruled out many career options, and made what I can do often much harder and less productive.

The first time I was hit with major adult depression I went almost overnight from being a high-flying Maths student to barely understanding anything the lecturers said. I was lucky. Results in the part one finals the year before were good enough to get me a degree, but other people have to drop out of university with no qualification.

A factor often overlooked, especially by medical professionals, is depression fallout. My sister and I were affected in a major way by our Dad’s repeated depression. Mum was affected far more. When depressed he could become demanding, extremely sensitive to anything out of place in the house, bad tempered, unpredictable. He often blamed Mum for everything that was wrong in his life. I was around sometimes when he’d have a knife at her throat and be threatening to kill her. The amazing thing is that she loved him and stuck with him till he died aged 85.

He’d also make sudden changes of mind which hurt other people; for instance one September he suddenly announced that ‘they’ had no right to know the details of his finances so there was no way he’d fill in my annual student grant application form. I started my teacher-training year severely depressed with no money.

That’s a brief and highly subjective summary. I’m working on an objective and rather more thorough description of what depression is, but you’ll have to wait for that.

* The Independent article is a response to a couple of recent publications in the UK:
Research has shown that although the number of people suffering depression has stayed more or less constant, prescriptions for anti-depressant drugs has doubled in 14 years. The original BMJ article is aimed at medics but may be found here.
Also our National Institute for Clinical Excellence (NICE) has just published updated guidelines for the treatment of depression in adults. The full report is 580 pages. Even the quick reference guide is 28 pages. This is not for the faint-hearted. Some degree of training and knowledge is needed before trying to apply the guidance. If you’re really interested you’ll find it here.

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The full British Medical Journal article is here.

Some points that may not be clear:

• If you have been prescribed an antidepressant then be sure to consult your doctor before changing how much you take. Stopping it suddenly can have unexpected bad effects.
• It would be easy to jump to the wrong conclusion, but in fact it may be absolutely right for a doctor to prescribe an antidepressant to someone under 25. The research simply emphasises the need for the mental state to be more frequently and carefully monitored than for someone over 25.
• This is not ‘new’ research. It is a clever and worthwhile analysis of several hundred previous research projects which involved nearly a hundred thousand patients. With this number of people involved we can assume the findings are reliable.

There are a couple of previous posts looking at whether or not medication has any place in treating mental illness. They are at Myth 2 : All I need is the right tablets and at Myth 3 : I don’t need tablets.

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Interesting advice. It makes a number of assumptions.

For a start it assumes you can just stop taking an anti-depressant or mood stabiliser. In fact this can be dangerous. It really is quite important to only change medication guided by a professional. If you are determined to give up the tablets completely then do make sure you find out the safe way to come off them.

It also states that such medicines are ‘poisoning’ your body, but that is a terribly vague accusation. What does it mean? A poison is something you take into your body in some way which either worsens your health or damages part of your physical body. A medicine may have some negative effects, but these should be balanced against any improvements. If something makes me a bit nauseous but takes away my depression then it’s probably worth continuing with. If it makes me vomit several times a week and is slowly damaging my stomach lining then probably not. There’s a sense in which the depression itself is a poison. Maybe a trade-off is acceptable.

And what are ‘natural’ methods? Can they ‘fix’ depression?

There’s a range of methods that have been developed which do not involve tablets. They can be helpful. They can make a dramatic difference. One course of counselling I had was very helpful indeed, but it was an hour a week for eighteen months, I did not enjoy the sessions, and the therapist was highly trained and very experienced. On another occasion (a two day NLP course) I enjoyed trying with one of the other students a technique involving colliding two sets of anchors. It gave me a tool I could use to reduce nervousness in a range of situations, but I was not seriously depressed at the time and I did have expert tuition and guidance.

One problem is that when you’re very depressed you probably cannot cope with most types of psychological or counselling help. For some types of counselling you need to be able to think reasonably clearly if the techniques are to help. Some time back a friend was referred to a psychiatric day ward with severe depression and a constant desire to commit suicide. The nurses had almost no time to work with the patients (What is it psychiatric nurses do all day? Obviously something, but aren’t they there primarily for the patients?). My friend was given an excellent book of CBT exercises and told to work with it on her own. She simply was not able to. She was still too ill, and anyway CBT needs to be assisted by a trained and sympathetic counsellor.

If you’re at a a mild phase in your depression you may well be able to benefit from the right type of counselling, but if you’re bad then it makes sense to take prescribed drugs in order to feel well enough to do something for yourself. I could argue that this is all the medication should be for, but I know I’ve needed antidepressants to cope with normal life for decades. Without them I could not have taken advantage of other therapies.

In most cases depression requires a holistic approach. Medication may be needed to improve your brain chemistry. You may need to look at all aspects of your current life, maybe change your job, learn problem-solving skills, deal with internal conflicts, and so on. Maybe you should change your diet and get regular exercise. The different approaches work together to help you make permanent improvements. Respect all of them.

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With depression there is no magic pill, although occasionally it might feel like that. I haven’t felt as good since I was 14 as when a few years ago I switched from one antidepressant to another. The new one was like someone injecting sunshine and energy into me. The effect reduced over a few months, but I still recapture it most years if only for a while. Medication comes with limitations, and it can be useful to understand this. Here are some potential limitations of any anti-depressant:

• Medicines are being improved year by year. Occasionally there’s a major breakthrough such as when the first SSRI was discovered. SSRI? I’ll explain that in a later article, but if I say Prozac you’ll probably understand. It was a new way to try tackling depression. It was called the sunshine drug. It has proved to be the best so far for me (but it is not right for everyone – follow professional advice. Under no circumstances try buying it over the internet; the risk is too great).I had to wait thirty years for Prozac. My father wasn’t so lucky; they invented it too late.
  My point is that the drug you really need may not yet have been invented.
• Teenagers (and cats) do not respond to antidepressants in the same way as adult humans. The medicine may be totally ineffective. I’ve heard there can be odd and potentially dangerous side effects. Teenage depression is different from adult depression, and if serious it needs expert professional help. (See Myth 3 coming soon.) And cats? Before vets in this country were so tied up in red tape our cat was prescribed a mild tranquiliser. As predicted it had no discernible tranquilising effect, but did restore his appetite. Creepy.
  It may be hard or impossible to identify a suitable antidepressant for a teenager, so other methods are needed.
• Two people with identical depressive symptoms can react quite differently to the same medication. There are so many factors to be considered, and some are very well hidden. Psychiatrists are not magicians. Sometimes they need to try you on something for a while. It feels absurd, but a bit of supervised trial and error may be necessary. And then, of course, there may be no medicine on the market yet that helps you. Chill. There are other therapies available.
• All medicines have side effects. Check out the information leaflet in any pack of medicine in the UK and you’ll see a frightening list of possibilities. Relax, you are very unlikely to get most of them. With luck you may not experience any of them. The list is there in case, so my approach is to not read it unless something changes after I start taking the medicine. If there’s anything dangerous to watch out for your doctor will have told you. The exception to this is anything fairly new on the market. In the eighties my consultant put me on something only recently approved for use. It was fantastic, although a little too much so. I was a bit high for about a month till he contacted me to tell me to stop the tablets and come back in to see him; apparently around the world too many people on that drug had died. Ah well. Another medicine I tried for six years took away most of the taste of food, made steak taste like cardboard, and often made me nauseous. If it had worked then fine, but it didn’t.
• Some antidepressants tend to make people a bit drowsy. I was on one for a couple of years. The morning after I first took it I slept through the alarm and woke up after lunchtime feeling like a mule had kicked me in the head. To be honest it never really helped me. Initially I had difficulty concentrating enough to read more than a couple of pages of even an easy novel. Textbooks? Forget it. I loosely estimated my IQ dropped at least thirty points for the two years. This is okay for some people provided the depression is eased significantly in the process, but whenever I can’t think clearly or read extensively I start to feel down and the depression gets worse. For me the result is that the dopiness caused by the tablets actually makes me feel in some ways more depressed. According to the textbook this should have been the best drug for me, but in fact it wasn’t.
• An antidepressant may help you through an extended bad spell, but it can only ever treat your body and brain chemistry. This may be enough. For you sake I hope so, but no chemical can resolve underlying issues. It can’t sort out destructive childhood memories. It can’t teach you how to socialise – although it may make you feel well enough to experiment in social situations. It doesn’t provide problem solving skills.
• The good effects may not last. Maybe you’ll need to go back to a less helpful medicine for a year or two and then return to the best one. That’s life. Let’s enjoy it as much as possible, and benefit as many other people as we can.

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