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Physiology of depression: Discussion with Andrew Schuman GP

Physiology of Depression: Discussion with Andrew Schuman GP
So, Andrew, is it possible to define depression? It is, and we do, but I have an increasing difficulty with overall unifying diagnosis inasmuch as people’s experience of depression is many and various. I think increasingly, I realised and I think we all realised that one person’s experience is entirely different from someone else’s. Nevertheless, we have to have some sort of working diagnosis. So we have a condition now termed Major Depressive Disorder, which encompasses a range of symptoms of depression. So you can’t say someone easily has or hasn’t with a blood test, for example, as you can do with diabetes.
But what we do is we– so there’s many features of depression, some of which everyone has– everyone will have had at some point in their lives. So feeling low, feeling very inactive, sluggish, not interested, not motivated, unable to concentrate, tired, poor sleep, not wanting to eat, maybe losing weight, maybe feeling guilty about it. So all these things are normal characteristics, but if you have too many at one time that’s what we term depression. So almost like a tick box or not a tick box? It is a bit like a tick box.
Yeah, although the quality of your experience is what– so I wouldn’t add up your– if you came to me as a patient– add up and say, that does or doesn’t constitute depression. It’s more to do with the quality of or depth of your experience of those symptoms. Nevertheless, we do tend to add up and we categorise broadly into mild form of depression, moderate, and severe. And that will determine how we manage and treat. Do you think it’s on the rise? Do you find that you’re meeting more patients with depression than you did, say, I don’t know. 10 years ago. Yes. Undoubtedly, I think everyone would agree with that. And there are many reasons for that.
One of which is, and I think Britain’s been described as the depressive capital of Europe. We don’t do well on depression, and there are many reasons for that. To do with– societal reasons. But also the good thing is that people are more ready to come forward and seek help. We’re trying to destigmatise all the time. And the stigma– we’ve had that stigma for– And that’s a constant battle and we’re constantly trying to lessen that, do away with that, be aware of it, and manage that. But that’s a constant battle, but it’s certainly on the rise.
In terms of figures– and there’s big wide variation across the world– Japan seems to have the lowest incidence, and again there are many reasons for that, of about 3% over someone’s lifetime, of having depression, whereas in America it’s about 17%. So quite a difference. Here it’s about a 10% chance over your entire lifespan of having a significant bout of depression. One of the texts that we were looking at was Burton’s book about melancholy, which dates from 1621. And I love that because it seems to me that the advice he gives is not wholly dissimilar to what I feel a contemporary GP would give. So he says things like, exercise, healthy diet, talk to a pal. What’s the other one?
Have meaningful work. Does that resonate? Yes. Absolutely. I think that’s very, very similar to what we prescribe now. And we have modern pharmacological treatments as well and psychotherapy, counselling. But I mean, broadly, those things are what we start with, and those things are what we often rely on. Those things we rely on long-term as well. Can anyone be affected by depression? I think anyone can be, absolutely, and often unexpectedly. And I think it’s helpful when such people write about the experience. So William Styron, a hugely successful writer– he wrote Sophie’s Choice amongst many other extraordinary novels– I think the book starts with him at a prize-giving and he can’t go. No interest. Completely shocked by how he’s feeling.
And he just feels– and it took him by surprise. So I mean, anyone can do. Now, what would we have called it because I’m quite fascinated by the history of depression and the term because in Shakespeare’s time, as you well know, they talk about melancholy. And then Samuel Johnson does actually talk about depressed spirits and famously talked about ‘the black dog’ for his own battles with depression. So when did that gain currency, the word depression? Was that a 20th century thing? My understanding is it’s more of a 20th century description of what has always existed, whether one calls it sadness, melancholia.
We would use the term, broadly-defined depression, as endogenous, so arising from within. What one would call melancholia. For no reason I feel this oppressive sadness, as opposed to say reactive depression when you suffer bereavement or something awful happens, something traumatic happens, and then depression follows. And that’s explicable, but the course of the two are quite different. I think Hamlet’s quite interesting on that, which is another one of our texts, because Hamlet talks about putting on an antic disposition pretending to be mad, but in fact he’s clearly somebody in the grips of depression as a result of losing a loved one. Do you see that sort of thing happening? Absolutely, yes.
And the challenge is not to miss depression itself, but also not to confuse the two and there’s massive overlap between a normal human grief reaction and a depressive illness. So one can slide into the other, but they don’t necessarily follow, and someone with many features of depression who’s grieving is not depressed. And therefore, it’s probably wrong in many of those situations to say, treat them medically with antidepressants. I just wanted to ask about the treatments. So obviously, antidepressants can be extremely useful. But there are other methods, and one of the things we’re interested in in the course is to suggest the idea that mindful reading or reading of poetry can help for some people– not for everybody, for some people.
Have you ever had experience of a patient who you think has been helped by the written word? Yes, I have had a number, and I think in general practice when I get to know my patients, you can talk about these. And I know– I know when they’ll want to talk about it. Also when in the face of depression– in the grip of depression, I’m not going to start bringing up poetry. And that may be when antidepressants or talking therapies, psychology and counselling, are most relevant. But in the longer-term, also the prevention of further relapse into depression. So taking the longer-term view, and that’s in many ways what mindfulness does. It takes the longer-term view. It’s there as a preventative.
If someone has recurrent bouts of depression, how do we manage that in the future? So it’s looking long, long term. The writer Rachel Kelly who writes a brilliant book about depression, Black Rainbow. She says that poetry saved her from depression when nothing else worked. Have you ever come to that? Yeah, and I think I’ve got an example here of a patient recently who has had a long, long history of depression and I’ve more recently been personally involved in different forms of antidepressants. He’s had, I know, a range of different psycho-therapeutic approaches, counselling, and they’ve all kind of helped, but in his case they haven’t made the difference long-term. And I said, ‘what does make all the difference?
What makes the difference, if anything has, what has? Which of those?’ And he said, actually, it was reading. It was writing. It was poetry.
Here, Dr Andrew Schuman talks to us about the symptoms of depression, as well as about how it is diagnosed and how it can be treated.
Although many of the symptoms of depression – such as poor sleep, lack of energy or difficulty concentrating – will be experienced by almost everybody at some point during their lives, it is the combination of symptoms, as well as their intensity and their duration, that characterises depression. In Andrew’s experience as a general practitioner, rates of diagnosed depression are on the rise. He suggests that public awareness of the condition is improving, and talks about the different ways of managing depression, which can include pharmacological treatments, as well as occupational therapy, counselling and maintaining a healthy, active lifestyle. As a GP, Andrew is also open to the concept of poetry as therapy, suggesting that reading, like Mindfulness, might be particularly effective in preventing the recurrence of depressive episodes.
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Literature and Mental Health: Reading for Wellbeing

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