Читать книгу Understanding the Depressions - Wyn Bramley - Страница 4

What Are

“The Depressions”?

Out, out, brief candle

Life’s but a walking shadow, a poor player,

That struts and frets his hour upon the stage,

And then is heard no more. It is a tale

Told by an idiot, full of sound and fury,

Signifying nothing

William Shakespeare (Macbeth)

We all share identical properties that mark us out as human beings. Even so, every person is unique: we are not clones. It’s the same with depression – or perhaps more properly the depressions (plural) – because they manifest in so many different ways and under different circumstances yet in essence remain the same. This is a simple enough observation, yet there appears to be little understanding of the condition – or conditions – among the general public, who tend to lump together all states of “feeling miserable” into something to be snapped out of, a disease category to be treated medically, or a feebleness of personality to be disapproved of and dismissed.

To test this assumption I conducted some amateur research at my local pub and shopping centre. I asked random people of varying ages the simple question “What do you think it means when people say they’re depressed?” Herewith a sample of replies: “It’s feeling wretched most of the time”, “a psychiatric illness”, “suicidal?”, “need to pull themselves together, stop feeling sorry for themselves”, “off their trolley, no such thing”, “just another excuse: get a life mate”, “everybody’s depressed, the state the world’s in”, “another way of saying very unhappy isn’t it, sort of stuck in sadness?”

These answers do show how vaguely understood depression is, though all respondents connected it with a negative outlook and feeling low. There is ample, largely professional knowledge concerning depression, how it shows itself to the outward observer or physician; but there’s very little understanding of what it actually feels like to be depressed (unless of course one suffers oneself). Perhaps folk have witnessed depression in others and fear contamination, though they know full well it isn’t contagious. Perhaps they’ve felt that awful sense of impotence when one tries fruitlessly to cheer up the sufferer, talk them out of their misery; better to steer clear.

A car park interview

Okay, so what does this seemingly scary state that we label “depression” actually consist of? The first thing about it that we need to take very seriously is its complexity and its variety. I’m going to say a bit about Frank, a talkative Yorkshire man, and his personal experience of his wife’s depression. This example shows how hard it is to simply seal off depression from its immediate context, as if it were an encapsulated thing like a growth that needs excising, or a bug that needs antibiotics. Depression transpires in a network of personal relationships – partners, kids, parents, work colleagues. It often destabilises the traditions, alliances, and problem-solving measures that have till now been the mainstay of the depressed person’s family or work group. (Occasionally though, someone’s depression grants an opportunity for all concerned to re-jig their shared relationships into a more wholesome way of operating. Some theorists claim that many depressions actually result from toxic family or workplace dynamics.) In trying to deal constructively with one’s own depression or someone else’s, this bigger picture has always to be taken into account if there is to be any benefit to those involved.

I met Frank at Tesco’s checkout where we fell to chatting. Once outside I put my survey question to him. It was spitting with rain and to my surprise he pulled me by my arm toward the sheltered bit of the car park. He plonked down his shopping bags and turned eagerly toward my enquiring face. “Aye lass, I can tell you all about depression. You can stick this in your blinking book ’cause no one really gets it. Somebody should tell ‘em.”

“My wife has got it – real bad, takes all the tablets and that. Can’t wake up in the morning till I pours three cups of strong tea down her, and even then she’s woozy – from bad dreams she says. I gets the kids off to school and packs me own lunchbox and off I goes. I gets home from the plant totally knackered around half six – bloody awful traffic. All I wants is some grub, bit of telly and bed.

“Now the missus, she bucks up in the evenings since she’s on them pills. Lipstick, cooks a nice meal, new frock. You know what she wants don’t you? Well I can’t. I’m a morning man in that department, alus was. So was she till she got depression. Then I gets tears, rage, doors banging. ‘You don’t love me anymore. You think I’m past it. I’m going to chuck that telly out the window!’ Aye, she gets right hysterical. What am I supposed to do? One minute I have to play Nursey, the next a ruddy stud. We never have any of the old conjugals now, neither of us tries, only way to keep the peace. We barely speak to each other. I’m miserable, the kids are miserable. What about my depression eh? I don’t get pills do I?”

Poor bloke didn’t know which way to turn; he needed desperately to offload onto someone. His story clearly demonstrates how inadequate a solely chemical approach is to something as multi-factorial as depression. We don’t know his wife’s circumstances, though she seems to be as worried as he about the marriage and their sexual relations. Did these difficulties cause the depression, you might ask, or were they its result? Was the wife having side effects from the drugs? Was hubbie really too tired at night, or secretly resentful that the depression took his wife away from him in the mornings when he most needed her? He certainly saw the depression as the enemy, almost a rival.

What does it feel like?

As illustrated by this example, the sufferer’s dark inner world inevitably impacts on their nearest and dearest. Relationships can be sorely tested. Sometimes the depressed person is only too aware of this, feeling increasingly guilty and self-reproachful. They try hard to disguise their mood until the effort becomes unsustainable and they collapse, to the surprise of others who had never suspected. In tragic cases suicide may prove the only escape from that Herculean effort of putting a good face on things, and the only way to protect family and friends from their “being a burden”.

Depression is primarily a mood disturbance, rather than a thought or behaviour one. We all have mood signatures with which our friends and colleagues are familiar. Some even-tempered people’s mood over time might be represented by a straight line. Others’ moods could be drawn like a wave, rocking gently up and down. Still others are stormy, peaks and troughs in the wave, moving rapidly from optimism to pessimism, buoyant one minute, gloomy and despondent the next. These signatures vary almost as much as written ones on legal documents. So long as the mood signature of a person remains more or less constant, they may be said to be free of mood disorder. Should someone who usually swings in mood become flat as a straight line for a sustained period though, perhaps friends should worry rather than feel reassured that peace has broken out!

Depressed mood is something we all experience. According to the dictionary, one definition of depression is a “sunken hollow place” and on a bad day that’s just what our whole organism – body, mind, and soul – feels like! This is a normal if unpleasant mood variation, which can occur without any especial stimulus, though often sad news, a bad decision or an unhappy event precedes it. Sometimes it will be worse and bother us for longer than usual. All the same, it runs its course before fading away and our characteristic mood sequence returns. This kind of temporary negativism is what we colloquially call depression but is not the subject of this book. This is not to minimise its importance, but it isn’t what we are concerned with here. Colloquial depression is well within the bounds of normal mental health – we can’t be happy all the time. However, any so-called depression that fails to resolve itself – becomes protracted, adversely affects otherwise good relationships, or causes the person to not enjoy their usual pleasures and interests – I’m going to mark as “little ‘d’” from now on to make clear we are in new territory. The person knows something is going wrong; they are up against psychological distress beyond common unhappiness.

What about “big ‘D’” then? I will use this to cover all those Depressions that without question require medical intervention on top of any other help; they have to be defined as an illness, whatever other crises may be simultaneously occurring. They often recur on a regular or irregular basis so that the sufferer comes to know and better manage the warning signs. At the deepest point in the Depression there is serious suicidal risk and the person may lose the ability to be objective about their condition. Nevertheless, as with little ‘d’, there are degrees of severity and over the course of any Depressive episode mood can lift or sink from day to day, sometimes hour to hour or moment to moment. A grey area exists between little ‘d’ and big ‘D’ and when referring to this, or making a comment on all Depressions collectively, I will use the big ‘D’. I trust you’ll soon get used to this.

While we are talking about nomenclature, you will also be introduced to the idea of a Self (capital S). We all have a picture of the kind of person we would like to show to the world, beautiful and clever perhaps, or caring, or adventurous, creative or successful. At the end of each day, should we review how our actual Self performed, we may find ourselves happy with it or critical of it, disappointed in it or angry with it. We have a relationship with our Self that obviously impacts on mood if we are always at loggerheads with it. I will discuss Self Psychology in a later chapter.

A Depression of whatever sort describes a process – not an infection or a growth you have either “got” or not got, as my Tesco man seemed to think. An astute observer or an experienced sufferer can trace its course as it deepens, gets stuck a while, then gradually or suddenly lightens. People undergoing regular or intermittent Depressions, as well as their relatives, carers and counsellors, can benefit from identifying each step of the route toward illness and afterwards toward recovery. The terrain along the way may be ghastly but at least you know where you are and what to expect.

When does little ‘d’ become a medical matter?

At what point can we say someone is actually ill? Usually we deem a person sick when they can’t function well enough in their day to day relationships and job to ”keep the show on the road”. We call it a nervous breakdown. Our sympathies are mobilised. Depression is tricky however, because some sufferers inhabit two worlds at once. Shame, impossibly high standards, an over-developed sense of obligation or responsibility force some to carry on, whilst inside all is despair. From the outside they seem no different. So are they ill? Perhaps unhappiness becomes illness when a point is reached where pleasure in anything at all has become impossible (the text books call it anhedonia) and where hope has vanished from the horizon. Yet still some struggle on, keeping up appearances.

How it feels on the inside, not how it appears on the outside, is what in my view as a therapist defines the line that crosses into that domain where some kind of professional help is required. Many people who have to bear cyclical periods of this ailment, be this little or big ‘D’, know the oncoming signs so well (“Hello darkness my old friend” as the song goes) that they can identify the very second a lingering oppressive mood has become a Depression. One of my clients told me: “It’s like someone sticking a seat belt on you. There’s that noise in your head – clunk-click; you know with awful dread that you’re now strapped in, but it’s trapped in, really. No way out. You need help.”

From the point of view of family or friends there may no evidence to explain such a loss of vitality and the complete inability to fight it. Parading the sufferer’s achievements before them, listing the people who love them, urging them to think positive or look forward to their holiday is of no avail, for the mood state is now all-encompassing. The person can’t be cheered up or consoled, for whilst they are affected (Depressions do end!) there is no belief that optimistic ways to view the world are possible. This loss of the capacity for hope is the illness. This is what non sufferers find so hard to grasp. For them hope springs eternal, even in the direst circumstances. Hope is a survival mechanism so rooted in our make-up that we cling to it even when the game is clearly up. If you want to understand the Depressions, try to imagine what it must be like to lose this life-line.

There’s a huge discrepancy between how the sufferer sees the world now, and how they saw it when well. They may know that very well, but it makes not a jot of difference to them. Their negative perceptions feel like the truth to them, their previous “normality” an illusion. Arguing with them won’t get you anywhere. Reason makes no inroads into mood. Look at someone who has just fallen in love, is over the moon. You can prove beyond doubt that their lover is a crook, a cheat and a liar, but does it affect their buoyant mood? As with the Depressions, you need to bide your time.

If a Depressed person can be persuaded to describe accurately their interior experience, the listener may be shocked by its extremity, may feel the narrator must be lying or exaggerating. They are not. Part of their mind is “out of order” like a faulty washing machine stuck on only one setting. Their reason is perfectly intact, but their mood unalterable, their optimism button jammed. Is it any wonder partners and pals feel powerless to help, or become irritated and critical of the sufferer who sometimes looks as if they are stubbornly refusing to cheer up? They can’t cheer up. When the affected person’s state is at its lowest ebb, that negative mindset is experienced by them as a permanent, pitiless reality: what conceivable point is there in trying? This is not stubbornness, which after all requires some effort, but hopelessness, which renders effort impossible.

Signs and symptoms

Let’s now review the clinical symptoms in the Depressions, the kind of things diagnosing GPs are looking out for. Not all are evident in every case and some patients will present but a few. Usually, but not always, one feature dominates the rest. And we should be aware that little ‘d’ depression can slide in and out of big ‘D’ over a short or long time span, until it eventually becomes clear what kind of manifestation we are dealing with on a particular occasion. While this disordered (i.e. out of kilter with the usual) mood prevails, it’s essential that GPs, relatives, friends and counsellors desist from poking and prodding it as if it were a thing, an inconvenient lump to be surgically cut away, medicated or radiated out of existence. The Depressed person is psychologically isolated enough already, without making things worse by prioritising their symptoms over their person.

Medical considerations are only one among many when trying to help. My Tesco man was already edging toward small ‘d’ himself, because no one recognised his problems, and he looked likely to deteriorate. At the same time his wife was improving biochemically but was left to deal with the consequent sexual issues without aid. This couple received but crude and superficial assistance, the interpersonal dimension in the Depressions excluded entirely from the treatment plan – if there was a treatment plan! I will look at available physical and psychological treatments, with stories from those who underwent them, in a later chapter.

There are many physical manifestations of the Depressions, but they usually assert themselves first as a psychological disruption. The individual’s self-damning attitudes to, and negative judgements of, their own person are out of character. (It has to be admitted though, that some normally gloomy characters become Depressed and no one notices, due to the lack of contrast between their well mood and their gradually disordered one.) There is usually a pervasive aura of sadness and/or defeatism about the individual, or less commonly they emanate a smouldering rage against a cruel world. Typically the episode will have a distinct beginning, middle and end, and each phase may be fast or slow. Distorted, disproportionate, overly pessimistic beliefs and self-critical judgements flow from the low mood, gaining force or dissipating according to whether the episode is progressing or receding. All the same, recovery can be far from linear and tidy: two steps forward, one step back, is more common. In assessing any type of Depressive episode – what to do about it, when and how – the idea of time, the concept of ebb and flow, is of central importance.

In any helping role one needs and wants the collaboration of the sufferer. But if the mind that is out of order hates its own existence, can’t believe in the possibility of healing, will not or cannot ally with the helper, what can the helper do? Hard though it will prove, maybe they can learn how to wait and discreetly watch, keep the person safe, fed and watered, while trusting that a better time will come, when they will be allowed in.

Many sufferers, counsellors, relatives and carers will recognise the following picture of middling to big ‘D’. There is in addition to or in combination with the above, more pronounced self-loathing, excessive and unfounded guilt, overwhelming sensations of pointlessness, fatigue, even exhaustion. There can be emotional numbness or excessive irritability, inexplicable tears and/or regular involuntary sighing. The entire world may be perceived as irredeemably evil. This pervasive mood can’t be dislodged by any amount of rational argument, reassurance or proof that their mental state is inaccurate. The individual concerned often knows with their intellect that the way they are experiencing the world is unbalanced, that by all accounts they are perfectly successful, the world a wonderful as well as disaster-ridden place, that they have committed no major crime, and so on; but the internal atmosphere remains unchanged. Their chemistry, whether cause or effect of their mood, is instructing their evaluating brain to operate as if these delusional ideas were true.

On the other hand, as we all know from the news, there are at the farthest end of the Depression spectrum those people who have lost touch with reality altogether (are psychotic) and who tragically kill themselves and their families in a loving but misguided attempt to protect them from an uncaring world. This mercifully rare form of Depression differs from other psychoses such as mania or the schizophrenias in that the person may seem outwardly normal and so their illness goes undetected until disaster strikes.

Mixed pictures and the importance of assessment

Neither does a Depression of any kind inoculate you against other conditions. People who suffer anxiety or panic attacks can experience all the signs of a Depression, from the mildest to the most severe, with or without their usual symptoms being present. People with controlled eating disorders, chronic migraines, ongoing marital and family issues, addiction, post-traumatic stress, and learning difficulties can become both little ‘d’ and big ‘D’ affected, sometimes together with, but often quite independently of, their usual complaints. The new situation requires fresh investigation, but is frequently missed by counsellors and medics concentrating on the old familiar picture, as if, once labelled, their client was unchangeable.

Assessment is a delicate matter calling for time and skill. Separately or combined with other markers, the Depressions can feature in many other disorders – schizophrenia for instance, where thinking and perception (hearing voices, believing one is being spied on and so forth) dominate. The one set of symptoms doesn’t cancel out the other, but are they related, reinforcing one another? Or are we dealing with two distinct entities with different origins, perhaps requiring different management?

Similarly, social isolation and loneliness, especially in old age, can descend into one of the Depressions without anyone noticing. Loneliness creates the conditions for rumination, the surfacing of regrets, the missing of dead partners and friends. This “ordinary” colloquial depression may be tolerated till one day the sufferer appears in the GP’s surgery unable to carry on. Common unhappiness without neighbourly or family input easily degenerates into little ‘d’ or even, if neglected long enough, big ‘D’ Depression. Ever receding realistic hope of companionship leading to inner desolation is the main culprit here.

In summary then, symptoms of Depression may disguise other disorders or relationship problems that, once correctly diagnosed and attended to, can relieve the Depression symptoms quickly, or prevent little ‘d’ form turning into the big one! I will share real examples in future chapters.

The prescription pad may be very useful as part of a helping plan, but should not be pounced on as if it were a cure-all. A careful assessment needs to be made before any action is taken: family history, recent exacerbating or contributory life events, the current state of the subject’s personal relationships, their internal preoccupations, dreams, levels of pessimism, their eating and sleeping, plus reported or observed signs of physical slowing down. All these factors have a bearing on the Depressions. A thorough appreciation of any episode’s genesis, whether it stands alone or is part of a mix, whether it replicates or deviates from previous ones, can go some way toward preventing or better treating a further attack.

Counselling and psychotherapy

Counselling and psychotherapy have much to offer, if accessed at the right time and with the individual’s un-coerced agreement. If, for the moment, they are too drugged and woozy, or too lacking in hope to collaborate, it will be wiser to wait till any antidepressants have had some effect, so that the person’s mood is lifted just sufficiently for them to be able, however doubtfully, to take an interest in their own recovery. For another perceived failure could confirm their worst fears about themself, tear up their last shred of self-esteem. Marching them before a therapist may temporarily reassure the scared relative or partner, but could jeopardise or squander a future invaluable resource. Patience and tact are needful. Sadly there is no magic “cure” for all the Depressions or for the understandable anxiety and frustration of loved ones.

With help, those unfortunate enough to endure recurrent bouts of this malaise can come to recognise how their unique Depression operates – its personality so to speak. They know from experience it will come again, so they “do a deal” with it rather than fighting a war they can’t win. Alleviation strategies are at the ready, including drugs or not, depending on what has helped in the past. They find a philosophical outlook that enables them to live alongside it, much as malaria sufferers have to put up with relapses but refuse to let them contaminate other aspects of their life, the ones they so enjoy when well. The restless (and depressing!) search for a total “cure” is exchanged for a degree of grudging acceptance. With the help of wise counsel from someone who truly understands their private hell, they can develop ways of existing with, rather than raging against or totally surrendering to, this unwelcome visitor.

A one-off incident in a non-regular sufferer can sometimes be cleared up for good, once the antecedents are traced and come to terms with. Many episodes function like anaesthetic, numbing painful memories or traumas from the past that are threatening to re-emerge into consciousness. Often a marriage, a death, becoming a parent, divorcing, losing a job, triggers the mobilisation of long buried but unresolved historical issues. This delicate and deep work takes a professional skill that goes further than empathy and support. I will share true but anonymised stories about such therapeutic intervention in later chapters.

Counsellors and psychotherapists regard little ‘d’s and big ‘D’s as disordered mood states of the whole organism, not just some sequestered mental abnormality. Mind and body is one interrelated system. If you dissect a human corpse you’ll not find the mind anywhere. It’s an artifice, a construct that we deploy for the purposes of communicating with each other about our interior experiences. The body would be no more than a sophisticated robot without a mind, and the mind can’t come to life without the incorporated brain and its essential chemical, hormonal and electrical supplies. It’s for linguistic convenience only that we talk about the “mind” affecting the “body” and the “body” affecting the “mind”, for they are one and the same. We describe how these notionally separate units speak for one another, but really the whole organism is speaking for itself. The “mind” registers embarrassment, the physical face blushes. The student’s “mind” is saturated with anxiety as the exam paper is opened, but simultaneously their pulse races, their armpits stream with sweat, their heart thumps. The “physical” pain after the same surgical operation is experienced differently by different patients – requires more or less morphine – depending on their “mental” attitude to pain.

Whilst exploring quite other emotional or relationship matters with a client, the therapist is always on the look-out for signs that their client may be slowing down. Where there is persistent low mood, blood flow is sluggish, the skin pale; muscles don’t want to flex, there’s listlessness; digestion seems to stop and there are grumbles about constipation. The client reports that recently just lifting a kettle to make tea feels like carrying a boulder. Walking through the kitchen is wading through treacle. Lassitude makes the person crave their duvet, or alternatively dread and anxiety accompany all attempts at sleep. Recounting these changes as if they were oddities of little consequence, and preoccupied with other relationship worries, the client often fails to realise they are becoming Depressed. It falls to the therapist to remedy the situation.

Internal conflict in the Depressions

Internal conflict (opposing wishes and desires that are irreconcilable), both conscious and unconscious, is commonly associated with little ‘d’, and sometimes triggers a major Depressive episode in someone vulnerable to these. However conflict is not an absolute requirement for the diagnosis. As mentioned above, the loss of hope may come about through purely social causes, or multiple bereavements too overwhelming to absorb, or terminal illness that can’t be come to terms with. Some people are constitutionally susceptible to low mood, so that even small setbacks in their lives evaporate what little hope they normally entertain. The elements that make up a person’s constitution and how these might contribute toward the Depressions will be discussed in chapter two. Still, internal conflict demanding the anaesthesia of Depression is so frequent that it necessitates illustration.

Philip’s conflicts, conscious and hidden

Philip, fifty-six, unmarried, had always had a poor relationship with his Self. When he looked in the mirror he’d always seen a weedy sort of specimen, uninteresting, just about able to manage his lowly admin job and the house he shared with his widowed mother. A year ago she’d been diagnosed with Alzheimer’s and was going downhill quite quickly. There were no other surviving family members so his life appeared mapped out for the foreseeable future.

Then he met a lady chef in the canteen at work. She was also single, living alone in a bedsit. She had ailing parents in Ukraine, looked after by her bothers, to whom she was promised to return when her visa ran out in six months’ time. They both seized this last chance opportunity for happiness, shyly enjoying several months of courtship before Katya’s departure date loomed. She begged him to go home with her.

He couldn’t bear to put his mother in a nursing home though he longed to leave England and start a new, more optimistic life. He had for the first time encountered happiness, fulfilment, and he was already nearly sixty. He’d never in his life taken risks, put himself first. Surely he could allow himself this chance? Mum would need constant care soon in any case, so why not leave now? But she had looked after him all his lonely, under-confident life; how could he desert her now? The constant guilt and indecisiveness grew unbearable, and a few weeks before Katya was due to return home he suddenly sank into a torpor, uncommunicative, overcome with a sadness so immobilising and heavy he was unable to go to work. Despite her dementia, his mother in her more lucid periods, and Katya too, saw his decline and insisted he see someone.

It’s obvious why such a dilemma might make someone in Philip’s position very miserable, but did that warrant a complete shutdown? Why did he succumb to so dangerous an illness? The answer lies in an internal conflict of which Philip was completely ignorant until he commenced therapy and talked at length about his much loved mother.

Philip always emphasised his mother’s reliance on and need of him, as her only son; but in fact there had been another son, unexpectedly stillborn, whose name had already been chosen – Philip. The Philip described here was conceived very soon after and the dead infant never spoken of again. Philip learned of the baby by accident, overhearing his gran and a neighbour at the garden fence, so his questions had had to be answered. He couldn’t remember what his reaction had been at the time, but till now he’d assumed it was all forgotten, that life had just gone on as usual. He’d never introspected much and had always believed his childhood to have been rather dull, but happy enough. The only odd thing was that around each birthday he’d always felt unaccountably sad, never enjoyed his parties or presents much. He’d shrugged this off as “just one of those things”.

Over time in therapy we were able to reconstruct his forgotten childhood conflict, long buried but stirred up again by the new conflict over Katya and his mother. His young mind had decided that he must never enjoy life too much, never take centre stage and expect attention, never be too successful, or seek praise. For all these prizes would have been won at the expense of the child to whom they really belonged and who was denied any pleasure in them. His life had been purchased at the cost of his brother’s death. He could only justify his existence by comforting his mother for her terrible loss; that was his lifelong role if he was to avoid guilt and punishment for relishing life while his brother could not.

His late blooming love for Katya had dared him at last to defy brother and mother and for the first time live on his own terms in a new country (literally and metaphorically). He experienced a sense of wild liberation at the prospect, but in response to it an immediate guilt-soaked self-hatred that was so awful that both leaving and staying tortured him equally. He could live with neither option and sank into hopeless inertia.

Philip recognised at once – “like a light bulb going on” – this picture of himself standing in the shoes of his dead brother, taking on a massive responsibility that was never really his, with the result that he could never claim his life as his own. As the dead baby ceased to haunt him and he accepted he could not do his mother’s mourning for her, his mood lifted, along with his capacity to deal with the current conflict and its practical implications.

The couple decided they could not abandon their parents and parted, on the understanding that they would visit one another at Christmas, Easter and summer until nursing homes and/or parental deaths allowed them to be together. I don’t know if the commuting relationship survived, but Philip was now so eager to make up for lost time that I suspect he made sure that it did.

A summary of this chapter

The Depressions come in various types and in varying degrees. One can be a bit down but able to hide it (common unhappiness), down for a longer period and only able to function like a zombie (little ‘d’), or ill, sometimes so ill as to find life not worth the living (big ‘D’). They differ from periods of unhappiness which, though extremely painful, are usually connected with adverse external circumstances – war, cancer, divorce – that the person believes will one day resolve. However far into the future, no matter how long the tunnel, there will be light at the end of it. It is this hope, no matter how unrealistic, that keeps us all going. At the lowest point in a Depression there is nothing to wait for. Make no mistake: the sufferer is not swallowed up by self-pity, but by a dark internal universe that’s blind to hope.

Whatever its size, shape and duration, the disorder is not self-induced nor evidence of a weak personality. In World War I many soldiers were shot for showing signs of what we would nowadays call Depression. They were labelled cowards, traitors, nutcases, malingerers. Lack of backbone was supposedly the basis for symptoms, not causes beyond the soldiers’ conscious control (you do not – cannot – decide or un-decide to be Depressed). Churchill was a pretty brave chap and we all know that he intermittently succumbed to what he called his “Black Dog”.

The inter-related causes for the Depressions will be examined in the next chapter, though they remain unproven, inexactly measured and argued over, despite the most advanced research. My version of them arises more from clinical experience than academic research, though its general tenor would not be disputed by most professionals in the field.