Depression and neurotic disorders

  Not all psychiatric disorders involve the same break with reality found in psychoses. In fact the majority of patients seen by psychiatrists do not suffer from psychoses but from less devastating disorders. Most of these are characterized by persisting high levels of depression and anxiety. They used to be lumped together under the title of ‘neuroses’ but the term has become unfashionable in psychiatry. However, it is a useful term, albeit rather vague, and one that most people understand so it will be used here. Neuroses cause distress and suffering to those who have them and may not be at all obvious to others. They vary greatly in severity and many patients are able to lead normal lives (marrying and working) while coping with them. Some, however, can be as disabling as the psychoses.

Depression

  Depression is the commonest psychiatric disorder and affects about 15 per cent of us in our lifetime. The World Health Organization ranks it second to heart disease as a cause of lifelong disability worldwide. It appears to be becoming more common (particularly in the developed world), although some of this may be better detection, greater public awareness, and greater willingness to seek help. Luckily, with the advent of antidepressants and the development of more effective psychological treatments (e.g. cognitive behaviour therapy), it usually gets better fairly quickly. Most patients are treated by their family doctor and only the most severe get referred to psychiatrists. A proportion of depressed patients eventually become diagnosed as having bipolar disorder but here we focus on the ‘non-psychotic’ group.

  Depression is usually experienced as a profound sense of misery, a loss of hope in the future, and often associated with self-doubt and self-criticism. Tension and anxiety are very common, sleep is disturbed, and patients lose weight and find themselves unable to concentrate properly or get on with things. Tearfulness and thoughts of suicide are common and aches, pains, and health worries frequent. In more severe cases patients report ‘feeling nothing’ (being cold and empty, unable to enjoy anything) rather than sadness. Patients may also take to alcohol or drugs as self-medication, which almost always makes things worse. Depression differs from our normal periods of sadness by going on and on without relief, and the weight loss and poor sleep perpetuate it.

  Depression is three times more common in women than men. Some people are constitutionally or temperamentally more at risk of developing it but it is clearly influenced by life circumstances. It is much more common in those living in poverty, those who are unemployed, live alone, have few friends or who have painful or disabling physical illnesses. Early loss of a mother and a difficult childhood are associated with an increased risk of becoming depressed as an adult. Depression is also more likely to follow from severe personal problems (relationship break ups, exam failure, job loss, etc.).

  Helping people with depression almost always needs more than antidepressants (though these are very effective). Counselling, help to see a way forward, specific psychotherapy, and attention to ensuring a supportive social network are all needed. Understanding depression better has led to the recognition of just how important social networks and friendships are to people. These are not optional extras and few of us can survive without them. Providing such networks for young isolated mothers and their children in programmes such as Head Start in the US and Sure Start in the UK are national programmes that include strategies to prevent depression.

  Most of us will experience some periods of depression in our lives with all of the features above. Most of us will get over them spontaneously and fairly quickly. Indeed, it is possible to think of depression as a necessary and useful human process – a period when we can work through loss, acknowledge it properly, and find a new balance. At such times it is appropriate to withdraw a bit into ourselves and some psychoanalysts consider the ability to be depressed as an essential step towards personal maturity. Certainly people who don’t seem ever to be depressed strike us as different or odd. Psychiatrists have spent years trying to make a clear distinction between ‘clinical depression’ and ‘normal depression’ and, frankly, have failed. The difference is more one of degree than genetics or symptom pattern. If it goes on and on, or if the symptoms become unbearable, it needs to be treated; if it gets better on its own after a few weeks, then great.