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
