The Continuum Concept – why your sadness is not my depression

I recently read the piece you are about to read – a service user’s reaction to a recent media piece – and was totally blown away.  I’ve read this countless times, as I continue to try to understand mental health.  Charlotte is certainly one of my favourite service-user bloggers: award winning in last year’s “The World Of Mentalists” awards for her mood disorder blog Purple Persuasion, which I encourage you to read.  I’m grateful she has allowed me to reproduce this latest piece as I want to distribute it even wider.

If you contort your thinking, as I do, about depression as “illness” or “human experience”, then this may well illuminate things.  It did for me –

Modern medicine is widely held to be A Good Thing.  It is allowing us to live longer, healthier lives than at any other point in human history.  The media loves the story of a scientific breakthrough and the promise of yet more astounding treatments in years to come, whether through improved surgical techniques, gene therapy or new, more effective drug treatments.

Unless, that is, we’re talking about the modern medicine of psychiatry. Suddenly, the ground shifts and medication is viewed with suspicion, even disgust.  Antidepressants become “happy pills”; using drugs as directed by a doctor is described as being “hooked” or “addicted.”  Anyone who has taken meds for their mental health might be forgiven for wondering why their pills are viewed with suspicion, while medicines for cancer or for Parkinson’s or antiretrovirals are “wonder drugs” or “miracle cures.”

This week’s Guardian article by Giles Fraser (Taking pills for unhappiness) epitomised the woolly thinking that surrounds antidepressant use.  As so often with this kind of article, it’s not written by anyone who actually works in mental health, nor is it penned by someone with lived experience as a depressive.  But, hey, let’s not let a little thing like knowledge interfere with the writing of an opinion piece.

You can read the article for yourself, but in summary Fraser’s concern appears to be as follows.  There has been a large increase in the diagnosis of depression and the prescription of antidepressants (with Prozac [fluoxetine] singled out for mention).  This is because, in Fraser’s view, we have overmedicalised aspects of the human condition such as feeling “sad” or “pissed off” and labelled them “depression.”  Big Pharma, meanwhile, is always looking to develop lucrative drugs and encourages doctors to diagnose to fit in with available treatments, in a form of “reverse engineering.”  People, opines Fraser, are being given drugs for their misery despite the fact that their misery may be generated by social factors such as the uncertainty of zero hours contracts or a horrible home life.  If people are miserable and this cannot be improved by “doing a bit more exercise or being more sociable” giving them drugs is an insistence on “compulsory happiness” and a means of “shutting people up.”

I hardly know where to begin.

This piece appears to be based on pretty much no actual evidence and dreadfully faulty logic.  Fraser flings a statistic about increases in prescriptions for the ADHD drug Ritalin then asserts that, “the same thing has happened with depression and drugs like Prozac” without using one single figure (and he doesn’t explain what he means by “drugs like Prozac” – is he talking about SSRIs specifically, or all antidepressants?).  For Fraser, it is then a hop, skip and a jump into drawing on his personal experience to assess the necessity of antidepressant prescribing. Only here’s what you might have thought a commissioning editor might give a damn about: Fraser has no experience of depression at all.

I’ve tried explaining this before, and I wish I could do so in words of one syllable, but sadly psychiatry and pharmacology do not lend themselves to such a thing.  Giles, let me walk you through it: just because your misery hasn’t been pathological, that says nothing at all about the millions living with genuine depression. You have not even tried to engage with the continuum, or spectrum, of human suffering that lies at the heart of mental health.

The majority of people who, like you, do not have a mood disorder have moods “within normal range” – they are “euthymic.”  Yes, they experience mood fluctuation, often because of circumstances but sometimes for no obvious reason at all. Sometimes they are, like you, sad or pissed off, or feel unjustifiably cheery, because you are correct in saying that this is part of the normal human condition. Sometimes they might move a bit further along the continuum for a while, but unless they remain there, and unless their mood dips or raises to the point whereby their normal functioning is impaired, they are unlikely to interest the medical profession. The further away from neutral a person’s mood state, however, the more clear-cut the need for treatment and/or specialist intervention. The outer reaches, the manias and unwarranted euphorias, the moderate to severe depression, are beyond the scope of primary care and become the territory of the psychiatrist.

People can and will disagree about the point at which “normal” becomes “abnormal”, particularly since individuals have different baseline moods and temperaments. If someone seems bizarrely cheerful, is s/he just one of those irritatingly shiny, happy people, or are they spiralling into hypomania?  Does someone’s mental outlook represent developing depression, or are they generally the office Eeyore?  Much of the mental health work of the GP takes place here, in the disputed borderlands between clearly normal and clearly abnormal.  Deciding who to refer for talking therapies and who to refer to a specialist team, who might benefit from increased exercise and who requires immediate medication with antidepressants or anxiolytics.  But there is a line, a border, beyond which you are not going to get better without help, not even if you take up running and register for internet dating.  And here’s the thing: it really doesn’t matter how or why you become depressed, whether you have a family history of mood disorders, or you were abused as a child, or your girlfriend left you, or your firm was bought out and you have ben TUPE’d out of a stable job and placed on zero hours contract.  Depression is depression. Despair is despair.

Since you dwell in the normal zone, you’d need a leap of imagination to feel your way into what it might be like to go beyond sad, beyond miserable, into debilitating depression, into a sadness so acute that you cannot even get up or dress yourself, a sadness that stabs at your heart, where the things you are most looking forward to are sleep and perhaps death. In this zone, somebody tells you to take more exercise and you literally laugh until you cry (which doesn’t take long).

As you’re clearly not capable of this leap, it might have been nice if you spoke to some of the people who inhabit this zone.  Otherwise, you see, it’s like writing a piece about cancer and drawing on your experience of having once had a funny lump that disappeared after a couple of days.  There are so many people who will willingly tell you the truth about antidepressants: that they take them not because they are weak, or because they want to cheat their way to happiness, or they can’t be bothered to see if they cheer up again after running round the park, or because they are the unwitting dupes of the drug companies.  No, they take them because they don’t want to be in pain and they are trying to stay alive. Reducing horrific levels of pain? Keeping people alive?  Sounds like a medical miracle to me.

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.



3 thoughts on “The Continuum Concept – why your sadness is not my depression

  1. I don’t know… I mean, yes there’s a difference between being a bit down and being clinically depressed. This difference is often ignored by the sort of patronising people who suggest sunrise yoga or similar as a cure-all (nevermind that you can’t even crawl out of bed).

    However… everyone I’ve ever met, including myself, with clinical depression has had some adverse events or generally ongoing difficult circumstances in their life. In my case it’s a direct cause and there are PTSD-like elements – but I was still denied any help but medication for almost nine years.
    Once it starts, it spirals out of control… say you lose your job because you can’t cope, then after a while on benefits there are no employment opportunuties due to CV gaps, or only awful jobs that will put pressure on and make your mental health worse. Dealing with the benefits system now means slowly gaining stability only to have it snatched away and then relapse. Losing friends because they can’t comprehend what’s happening to you. Etc.
    Then years down the line you’ve been affected by the years of stigma, the lack of opportunity, ongoing pressures from inadequate living situations.

    These people, and this includes me, are clinically depressed, but we are not usually offered the help we need. Medication is readily available, pushed by some professionals in fact. But if it doesn’t work you can easily be labelled ‘treatment-resistant’ (one RMN actually said that the medication not working proved I wasn’t ill). I also had a doctor refuse to refer me for counselling unless I took anti-depressants, despite me clearly outlining the origin of my issues and saying I felt i desperately needed to talk it all through with someone (this was near the beginning and a lot of harm to me could have been prevented, not to mention £££’s cost to public purse).
    The point is, a holistic approach is necessary. And, THERAPY!!! Not basic CBT but something to actually address the real issues.

    And I think Giles made a good point about people working in zero-hour contracts and the like. Ok, hating your job isn’t depression. But people have different ‘breaking points’, so for some it will be that one pressure too much.
    This leads to the question the politicians don’t want us to ask – why are we making living conditions so intolerable that some ‘fall over the edge’ when they otherwise might not have?

    In short, I agreed with the gist of the original article although I think it’s a false dicohtomy between “mentally ill requiring meds” and “not ill just sad”. And I definitely think Giles should have mentioned the therapy side of things. As well as the social/holistic elements that may help an unwell person be significantly less unwell.

    I write all this with the greatest respect to Charlotte, and her wonderful blog. Although I’m broadly anti-medication in psychiatry (esp. in circumstances I’ve described), I want the best for everyone struggling and if meds help – that’s great. What we need to address is giving meds as the ONLY answer.

  2. Where did my comment go? I’m finding all the backlash against this article very hard to take because where does it leave us who have been scarred by life and need THERAPY not drugs? Said it more eloquently in my original comment :/

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