The continuum concept: why your sadness is not my depression

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.

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About purplepersuasion

40 something service user, activist, writer and mother living with bipolar disorder. Proud winner of the Mark Hanson Prize for Digital Media at the Mind Media Awards #VMGMindAwards 2013. Winner of the World in Mentalists Mood Disorder blog 2012. Regular guest blogger for the International Bipolar Foundation http://www.internationalbipolarfoundation.org/ Expert by Experience working with Mind training department. Working on The Incoming Tide, a bipolar memoir. Find me on Twitter @BipolarBlogger or at my Facebook page http://www.facebook.com/BipolarBlogger
This entry was posted in Activism, Mental health, Stigma and discrimination and tagged , , , , , , , . Bookmark the permalink.

34 Responses to The continuum concept: why your sadness is not my depression

  1. tigtigs says:

    Wow!! This is just such a fantastic response that words don’t do it justice! I am SO SO tired of journalists and other writers making pronouncements on really important issues they don’t know about or understand. I hope that not many people will have stopped medication because of this article but some will I am sure.. I am fed up with having to explain why I am on medication and why, on the whole, it has kept me reasonably stable and non-suicidal for the past 10 years. I don’t need to explain..so I’m not! Keep up the good fight……..using whatever tools you need…Jenny

    • Thanks so much, Jenny! Means a lot to know that others think I got it “right” – although everything I write is of course my own perspective, it’s great to know that I have managed to say something that chimes so well with others 🙂

  2. Tim says:

    A well considered and thoughtful response.
    I personally don’t consider my medication any different than taking a vitamin supplement or a diabetic taking insulin and I believe those that try to paint the picture as something different do so in an attempt to remain comfortable in their ignorance.

    It’s reassuring that people like yourself can and do challenge the ignorance and stigma of others.
    Thank you

    • Thanks, Tim – I often use diabetes as a comparable condition, because in the early stages it can often be managed with lifestyle factors – but then there comes a point where medication in necessary. It’s pointless to tell someone with any life-threatening condition they should risk their life by doing without meds. C

  3. Pingback: Pill shaming, Giles Fraser and happy pills | Sectioned

  4. Stuart says:

    Superb response. Nothing else to add really.

  5. Gina Allnatt says:

    Best response I’ve seen to his drivel! As someone who was recently diagnosed with bipolar, and was feeling more and more desperate every day before I got prescribed the right meds, I thank you.

  6. Clutter says:

    Fantastic response to GF’s ignorant and arrogant pontificating on a subject he clearly has no understanding, comprehension or experience of as a sufferer or carer.

    If, as he supposes, excercise is the route to happiness, how are the physically disabled supposed to achieve it?

  7. phylor says:

    As someone dealing with mental and physical health issues, your writing on depression, it’s many faces, and the social stigma attached, is very poignant. A similar “discussion” by the press is the prescription of pain relieving drugs such as oxycodone.
    Yes, it is abused by some, but the majority use pain relieving drugs the way a depressive person uses anti-depressants: to make functioning possible. You are so right when these articles are only from one presective and little or no effort is made to actually talk to someone dealing with emotional or physical pain.
    A well-spoken response to a carelessly written article.

  8. drtonyryan says:

    Reblogged this on Tony Ryan's Incontrovertible Neurotransmissions* and commented:
    Giles Fraser in “talking nonsense” shocker

  9. Thank you, just…thank you. I wish I could forward this page to all my friends who just keep saying “I’ll get better, but you have to do it all by yourself”. You know what? I’ve been crying myself to sleep for the last four months, I’m not able to concentrate on anything but I have to, since I’m about to graduate. Both my psychologist and my physician agreed that I should at least try something, not because they are payed by Big Pharma or who knows what but because they think it wlll make me feel better and able to start functioning again.
    That’s all I have to say.
    Cheers from Italy

    • Hello Marta, I simply don’t understand it when people say, “You have to do it all by yourself.” The only thing I can liken it to would be people who haven’t had a baby tell others they have to give birth without drugs! If they haven’t been there, they can’t know, and anyway everyone’s suffering is different. If *you* feel you need meds and you care team agrees, that really ought to be good enough for anyone else. Really hope you can find something that works for you! Best wishes, C

  10. Cheryl says:

    So you still believe Big Pharma and their paid professionals? Let’s hope one day the penny drops. ‘Anti-depressants’ ‘work’ because of their placebo effect so you have in effect helped yourself because of your belief. Sadly you will also have the side effects!

    • Wow, what a patronising response. I don’t actually take antidepressants right now, but they *have* worked for me in the past, and right now the antispychotics are keeping my moods in check so that I can function. Reality check for you – *I* used to think like *you*. I was just as silly and naive and so self-rightous about “Big Pharma” that I turned away much needed help. *I* am the one for whom the penny dropped and I left my priggishness and conspiracy theories behind when I, quite frankly, grew up. Hope you can too one day and stop shaming the millions of people whose lives have been made a little less desperate. Please feel free to check my Twitter feed at @BipolarBlogger and read what vast numbers of people are saying about how their meds work for them.

      • What about us who meds didn’t work for? Are we not ill?

      • I have to say the many medictions I tried either did nothing or made me iller, horrible side effects. Even the ones that seemed to ‘work’ only bottled me up and made me start self-harming to try to cope with the pain that I could no longer let out by crying (couldn’t cry on AD’s). Of course, it will be different for others, but the experiences of those who were not helped by meds are just as valid as those who are.
        The comment you replied to wasn’t exactly thoughtful or sympathetic, but please remember some of us have good reason to dislike meds. And I do think Big Pharma pushes them and would love to medicate everyone – doesn’t mean there isn’t a reasonable place for medication though. Just would be better in the hands of public interest not private profit!
        I just find it a bit odd to be focussing on those who meds work for, when people can get meds far, far more easily than therapy or support. Trumpeting ‘the meds work for me’ does nothing to address what is actually lacking in mental health care – THERAPY (not breif CBT but proper therapy) and compassion and basic respect and kindness.

        Please don’t think I am ‘having a go’, I’m really trying to stay calm here, shaking as I write, because it makes me feel like somehow I’m not good enough. Like I wish i was someone with lots of supportive friends/family who could write about how meds helped me, and be a ‘good’ patient in the eyes of the professionals. Rather than finding my depression has affected every area of my life, barely anyone understands, and the meds provided no relief and I was seen as ‘treatment-resistant’ despite them not trying therapy (they are now). I’ve been through a lot of stuff that’s really affected me and it’s perverse how my quite legitimate struggles were dismissed as ‘just being mental’ when psychosocial interventions would have spared a great deal of pain. That’s where the borders of mental illness and ‘normality’ are blurred. (I guess PTSD is the most striking example.)

      • Oh dear, I would never want anyone to feel shaky about leaving me a comment, I really am interested to hear what other people have to say! One point I would make, though, is that *I* thought meds didn’t work for me, for ages and ages I thought I was *treatment resistant.” I wasn’t. I was misdiagnosed and being given the wrong type of drugs. And I am absolutely a fan of therapy, and have been lucky to have had NHS CBT and CAT. But please remember I was responding to very specific piece. And that piece was poor because it gave the message “meds are bad” by conflating people who are having painful life experiences with the clinically depressed. And that’s all I was responding to. I wasn’t saying meds are the only way. I wasn’t saying everyone benefits from meds. I was saying that when so many people feel they DO benefit from them, that in fact they have been lifesavers for them, it is ridiculous and patronising to say that those people are being “oppressed” by a cultural expectation they be happy. I promise I wasn’t commenting on anything else! C

      • Thanks for the response Charlotte – I will not be shaking typing any future messages!
        I did agree with the gist of the original article, and believe Giles is right that we are pushing some people over the edge, and making people severely depressed when they might have been mildly depressed. “People who are having painful life experiences” and “the clinically depressed” are not mutually exclusive – distressing and difficult life experiences, especially when one has no support and there seems to be no way out of the situation, can cause depression in the long run. This is what happened to me. If there had been things like adequate housing and employment opporunities, things would have been significantly easier and many further distressing events would not have happened (‘distressing’ is an inadequate word perhaps; I mean events that shaped my whole outlook and gave me PTSD-like symptoms).
        I do believe the original article was very carelessly written though!

      • You know what, I think it was the carelessness that was so upsetting to many. Just one line showing he understood the difference between stress/grief/unhappiness that is a process to be worked through, and something beyond that would have avoided the whole thing. It’s annoying when so many people are careful to provide evidence when they are only writing a blog, and then national newspapers pay people for sloppy writing!

    • Clutter says:

      You’re talking out of your rear!

      If I were suffering side effects from the AD I’m taking I’d have to balance the side effects against the very real benefits I get from them. On the other hand, I am experiencing side effects from the thyroid replacement hormone I take but have to tolerate them or die within 3-6 months.

      My meds are not lifestyle choices. They enable me to function to the best of my ability and within the limitations of current medical knowledge and pharmacology.

    • werehorse says:

      If it’s all placebo effect then why doesn’t the first medication tried always help?

      • Dawn says:

        very good point werehorse. I tried many different antidepressants that didn’t work, and one that made me much, much worse! I would have welcomed a placebo effect with open arms. Eventually after much trial and error I wound up on an antidepressant/mood stabiliser combination after seeing a professor in London. Even after all this my suicidal thoughts have never totally disappeared, so the ‘happy pills’ (as they are so offensively called) are far from being placebos for everyone, Cheryl.

        Great article purplepersuasion, and good luck to everyone who lives outside that euthymic zone.

  11. This is a great post. I read the article that you retweeted last night (I’m in Aus so it’s 12am Monday here) and I couldn’t believe that an article like that had been allowed to be published. I’ve been on a myriad of medication over the last 11 years, some have been good and some not so much. This year I stopped my anti depressant, and noticed that there wasn’t a great deal of difference. I had been on the same med for the last 6 years so there was a good chance it had reached it’s natural end. I started a new medication a few months ago and noticed a change after a week. Antidepressants are not the complete fix, but with them I have a lot less days in bed, than I do without.

  12. Joyce says:

    I have Borderline Personality Disorder. We feel things 10 times more intensely than others feel them, including depression and anxiety. Medication is usually needed at the start of treatment, and then therapy, usually Dialectical Behaviour Therapy or DBT. Sometimes, you may need to continue taking medication or you may be doing well for a while, and then relapse and have to start taking medication again. As Dr. Marsha Linehan, creator of DBT and a sufferer herself said, “People with BPD are like people with third-degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” Does that sound like sometime that just “thinking happy thoughts” or going for a walk in the park will cure? I don’t think so! As a matter of fact, I KNOW SO BECAUSE I LIVE IT EVERY DAY OF MY LIFE! Please check out my website to learn more about BPD:

    http://makebpdstigmafree.wordpress.com/

    Thank you for this post! I hope people understand a little better reading this!

  13. Karen says:

    Excellent post. I’m going to share it. Having suffered from severe anxiety most of my life, then eating disorders, then Post Natal Depression, it drives me up the walk when people who have no idea what it feels like to be struggling with any sort of mental health issue, tell us what will help us, and that medicines are evil!

  14. “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.”
    I’d agree with this (I have longstanding depression, sometimes anxiety, and sort-of PTSD symptoms though no official diagnosis of that). However, surely if you’ve become depressed due to overwhelming life events (eg. abuse) then it points at an urgent need of therapy, with or without complementary meds?
    That’s the problem I think he’s trying to get at: if we f*ck each other up, why are we giving pills as the answer and not helping the person deal with the actual issues? It seems like so many are desperate for therapy, desperate to make sense of the horrible things they’ve experienced – yet they are only given meds. Also, antidepressants do not work for everyone, and there IS evdience that ‘big pharma’ has overstated their effectiveness. So what of those, like me, that medication doesn’t work for, because our problems originate from life events not brain chemistry? (Although life effects brain chemistry so not all clear cut!) Remember he was talking of depression, which to the (neurotypical) majority means unipolar, not bipolar or any other psychiatric illnessness.
    I think Giles was talking more about fringe cases too, and clumsily making a point about individual difference. In fact I think the whole article missed some vital stuff to put it in perspective, such as mentioning therapy. But ultimitely, if we make life harder for people (unstable working patterns, worries over increased cost of living etc), then more people will not be able to fit into the narrow confines of what’s expected of them. Stress is a contributing factor to developing depression. Also, there will be many people – in fact I’d say everyone – who suffers depression who can be helped (or hindered) to some degree by society/social factors. Think of the people pushed over the edge by the Atos ESA assessments. And if people recieved the same support (and lack of stigma!) for depression as for a physical illness, it would help them at least manage it to some degree, rather than feeling worse and worse due to the stigma and isolation society so often inflicts on the mentally ill.
    Also, ‘Big Pharma’ does seem to want to medicalise everyone. It’s not mutually exclusive: meds or not ill. I wish you could get your meds from a non-profit company rather than someone making profits off illness… not that I wish you didn’t have meds! I think the money paid by private companies to push their product does influence mental health care (more so in U.S.) as well as the reluctance of politicians and wider society to actually spend money on therapies.

    But please don’t leave people like me out in the cold because our depression comes from the many adverse life expereinces we’ve had. (An yes, it is severe in my case, my life is blighted by this, despite asking for therapy for 9 years. Just starting it now, finally! I’ve been through more horrible/overwhelming events because I was only given meds earlier which didn’t work on me, and being ill was unable to escape awful siuations that then made my mental health even worse).

  15. Pingback: The continuum concept: why your sadness is not my depression | Stop Stigma

  16. I wasn’t sure which side of the fence I was on…. I wasn’t sure if my depression was circumstantial due to joblessness etc. Until I stopped my antideps (I accidentally ran out) and went back to misery, non-stop crying and not being able to function (even though I do have a job now).They work for me that’s all I know and all I need to know.

    Not so much happy pills are they as… able to get through the day without breaking down completely pills. Great post

  17. David Vanden says:

    Speaking as one who has struggled with depression I agree with the original article. I am completely hooked and addicted to S,S.R.I.´s and do not think I will ever be able to get off them. Since taking medication my anxiety has become crippling and I have not been able to function anywherwe near the capacity that I used to be able to function. At first the anti -depressants gave me a buzz and a lift but after a while they completely destroyed me. I hate being dependent on wanting the next medication to be able to take me out of this as I can no longer do it for myself. I fell like an addict in every sense of the word and that is more or less how I now live. I try to respect the fact that medication has worked for some of you, but given my personal experience with it, I see psychiatrists and pharmauceutical companies as nothing more than legitimized pushers. There is an increasing body of evidence that maintains that anti-depressants and particularly S.S.R.I.´s destroy the very synapses they are perscribed to help. This is research by M.D.´s and pychiatrists. I don´t know why your experiences with anti-depressants have been advantageous while my experiences are the polar opposite, and I equate it to the phenomenon that some people are able to take illicit drugs and then stop without burning out synapses while
    othere

  18. David Vanden says:

    I didn´t get to finish. While others become chronically dependent and mu8ch lower functioning. I wish to God I had been the former. Anyway please understand that for many of us anti-depressants have become a very addictive self depricating experience.

    • At no point did I say a) antidepressants are always good, b) there are no problems coming off them (I had an awful time coming off venlafaxine myself) or c) that everyone should take them. You are arguing about points I simply did not make. The points I *did* make were that a lot of people find them useful especially for people with genuine and severe depression and that this is NOT the same as the “sadness” the author spoke of. I am sorry you had a bad time on antidepressants but you are criticising my piece for something it didn’t actually say. I appreciate this is a highly emotive issue, but clearly we’re not discussing the same thing here, sorry.

  19. Pingback: A more accepting age? Why stigma is nowhere near a thing of the past | purplepersuasion

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