Back in 2019 I reviewed a book about depression (see Lost connections – Why you’re depressed by Johann Hari (kimtasso.com)) which was dismissive of medication for depression. I still like the book’s ideas about “disconnection” being a cause of some low mood and depression. But I need to correct the misinformation in that book about the effectiveness of medication for treating depression. Since then I have completed a further two years studying to become a qualified therapist. Throughout that time I have been seeking a book (aimed at lay people rather than mental health professionals) that sets the record straight. I found it in this one so here is a Book review: Mending the mind – The art and science of overcoming clinical depression (2021) by Oliver Kamm.
Author Oliver Kamm is not a mental health professional but a UK journalist (notably for The Times) who applied his investigative skills to explore the effective treatment of depression. He also eloquently and bravely describes how he experienced clinical depression. So if you want to know what it feels like to have a mental illness like depression you should read this book. Your empathy with those suffering from the condition will be significantly enhanced.
I took away two important messages from the book:
- Medication (prescribed by a GP or psychiatrist) can really help reduce the symptoms of depression so that you can live your life and start to recover
- Talking therapies – particularly Cognitive Based Therapy (CBT) – can be a vital tool in helping you to recover from depression. The author is rather dismissive of another talking therapy – psychoanalysis (which focuses on your early years and past) – in its effectiveness in helping those with depression although this was largely based on his experiences with one particular therapist.
The material in the following sections was of particular interest:
“It unhinges us from everything we thought we knew about the world and estranges us from every other person…the most immediate effect is likely to be loneliness”
“The global pandemic may decisively alter the debate on mental health policy…Dr like Van Hoof, a Belgian clinical psychologist has noted that around the world some 2.6 billion people are in some kind of lockdown, which is ‘arguably the largest psychological experiment ever’…the emotional difficulties experienced by those in lockdown are not inevitably the same as illness”.
“The mind can be mended to guard against the experience of depression happening again, and to speed its departure if it does reoccur”.
Part 1 – Understanding depression
What is depression?
“That episode was the beginning of a long and precipitous descent into mental chaos…Depression was by far the worst experience of my life”.
“The World Health Organisation (WHO) estimates that more than 264 million people of all ages currently live with depression”
“An academic study in 2013 concluded that depression is the predominant mental health problem worldwide, followed by anxiety, schizophrenia and bipolar disorder…In twenty-six countries, depression was the main cause of disability”
“They indicate that in 2014 almost a fifth of the population of the UK aged sixteen or over exhibited symptoms of anxiety or depression…the percentage was higher among women (22.5%) than men (16.8%)”
For diagnosis, the researchers in the UK use the WHO’s International Classification of Diseases (ICD) for clinical reasons. ICD-10 depression diagnostic criteria – General Practice notebook (gpnotebook.com) The technical name for mild depression is dysthymia.
“The WHO estimates that each year almost 800,000 people globally take their own lives and that depression is the major contributor to these deaths”.
What causes depression?
“The depressive state is coterminous with humanity. It sometimes erupts at a particular stage of life”.
“There was no definable trigger for this state other than the vicissitudes of life”
“Psychologists have considered why the experience of dissatisfaction and turmoil in middle life is so common…in an influential paper in 2008, the economists Andrew Oswald and David Blanchflower presented ‘evidence that psychological well-being is U-shaped through life”.
“The Easterlin paradox that once a developed country crosses a certain threshold of average income, growth in GDP per head doesn’t translate into greater happiness”.
“All I can confidently say is that, while there were environmental triggers for depression, the cause of it was internal”.
“Most depressed people differ from other people in two ways. First, their amygdala (brain structure which promotes the fight-or-flight response) is over-reactive. Secondly, much of their pre-frontal cortex (the more conscious region which normally regulates our emotions and reactions) is underactive”.
He then explores diverse historical theories of depression including:
- caused by evil spirits
- reductionism (physiology)
- dualism (mind and body are two separate entities)
- neuroscience to understand that function of different parts of the brain
- public debates about chemical imbalances (the monoamine theory of depression) and a deficiency of neurotransmitters (especially serotonin)
- Aaron Beck’s idea that clinical depression can be caused by distorted thinking
- Bullmore’s thought that levels of inflammatory proteins are a cause of depression
“The prudent conclusion for now is that there is no single explanation for depression, which has a variety of interacting causes…depression is physiological in origin, not spiritual”.
How we understand depression
The author looks at how Shakespeare described depression in Hamlet, the experiences of those who survived the Holocaust and literature references to melancholia and nerves.
“Psychologists and psychiatrists categorise depressions having four broad characteristics: affect, cognitive strangeness, behavioural symptoms and symptoms of external appearance”.
“It wasn’t that I had taken leave of my senses but my senses had taken leave of me. I wanted nothing more than for those senses, the real me, to come back…All I could think of, on and on, was the oblivion of sleep, which wouldn’t come, and how merciful it would be not to wake up again”.
There’s an interesting diversion into evolution, natural selection and adaptation and whether depression serves to collectively calm intra-group disputes.
How we misunderstand depression
“There are stubborn impediments to recognising depressive disorder. The one that concerns me most is the blizzard of misunderstanding that surrounds public discussion of depression and the consequent difficulty that many sufferers have in owning up to it…it conveys ideas that mental disorder is a sign of weakness and that the remedy is in the sufferer’s hands”.
“Some critics charge that citizens of affluent western societies are infantilised by a ‘therapy culture’”.
There are mentions of how celebrities such as Frank Furedi, Piers Morgan, Janet Street-Porter, Stephen Fry, Ruby Wax and Alastair Campbell have talked about depression. And there’s mention of public health policy incorporating the principle of ‘parity of esteem’ (i.e. mental health must be accorded equal priority with physical health). There’s debate about “wide” definitions about depression.
In asserting that we need to talk about depression he says the stigma attaching to the illness must be dispelled.
Part 2 – Treating depression
From page 125 he talks about the human yearning for fellowship, how depression creates a sense of shame so invites are not accepted. He reports how his close friends came together to ensure that he wasn’t left alone.
He describes his first experience of being referred to a therapist by a counselling hotline. The (psychodynamic) therapist – who thought the reasons for his distress would be uncovered by exploring feelings about past events – suggested they meet three times a week “The therapist’s intentions were good-hearted, but it was a destructive encounter”.
He sought guidance on the science of mental disorder and was put in touch mental health campaigner Lord Dennis Stevenson. Who, after talking to him for a few hours, suggested he was suffering from clinical depression. His work colleagues had already noticed something was wrong and sent him to the inhouse doctor. He was prescribed anti-depressants and a psychological therapy of a different kind.
The following two chapters summarise the historical search for treatments for depression.
This history starts with custodial institutions (asylums such as the Bedlam Hospital) whose residents were dominated by poorer people. There follows harrowing stories of lobotomies and the use of Electro-Convulsive (ECT) therapy. ECT is still allowed by NICE in extreme situations although it is not clear how it works.
Then in the 1960s the pharmacological approach to depression gained momentum with a new generation of drugs. There are descriptions of TCAs (similar to SSRIs – which are ‘reuptake inhibitors’ to make more serotonin available) and MAOIs (which block an enzyme that breaks down serotonin) and their side-effects as well as more recent SNRIs, NDRIs and SARIs. He notes that one theory is that they work not by blocking reuptake of neurotransmitters but by increasing neuroplasticity (the theory is that depressed patients have impaired neuroplasticity making it hard for their brains to move on from a negative mindset).
There’s material on the use of psychedelics and anti-anxiety pills such as Prozac (Fluoxetine). He describes the backlash against antidepressants (such as Irving Kirsch, a Harvard psychologist, who takes issue with the entire notion that depression is caused by a chemical imbalance in the brain). Kirsch’s statistical analysis was found to be flawed by the European Psychiatric Association. Yet it was Kirsch’s work that was so influential to Johann Hari (see above comments Lost connections – Why you’re depressed by Johann Hari (kimtasso.com)). The author reminds the reader that the UK NHS advice is that treatment for depression “usually involves a combination of self-help, talking therapies and medicines”. The author continues “Even since Hari’s book appeared, the largest international study to date has confirmed that antidepressants do indeed outperform placebos”. But goes on to warn that “the data suggests that among younger patients – children, adolescents and young adults – there is a slight increase in suicidal thoughts when on a course of antidepressants” (this side effect has been publicised – especially for paroxetine – trade names Seroxat and Paxil).
The author describes his experience of taking medications – and explains that they make it easier for you to get better as they alleviate the symptoms.
He begins this section reminding us that the original approach – proposed by Freud – has been largely superseded. But notes that the work of Freud’s contemporary – Emil Kraepelin – ultimately proved more influential in treatments for depression. He describes his encounter with a psychodynamic therapist – who examined his formative years and listened.
He helpfully defines the difference between psychiatrists, psychologists and psychotherapists and warns that there are no compulsory training courses for therapists (I take his point about the lack of regulation although it is improving – membership of the NCS or BACP or other professional bodies (e.g. UKCP) have stringent requirements for the length and type of courses that must be attended and the many hours of supervised work that must be completed before being qualified and then further hours of supervised practice to become accredited – so people should check these things when choosing a therapist).
He also notes that psychotherapy techniques for dealing with depressive disorder are “quite speculative” but recognises its value in dealing with other emotional or relationship difficulties – not least by having a compassionate, non-judgemental person to listen. He further berates psychotherapists for having a conflict in interest to keep their clients talking.
He explains how his discussion with Dr John Williams – head of neuroscience and mental health at the Wellcome Trust – led to his discovery of the NICE guidelines on depression (Overview | Depression in adults: treatment and management | Guidance | NICE). And this led him to find a clinical psychologist who primarily used Cognitive Based Therapy (CBT – founded by Aaron Beck who saw the impact of distorted thoughts on feelings) and Socratic questioning which “showed me how to act directly on depressive thoughts and overcome them. She literally taught me to think again”. He notes the research evidence of the effectiveness of the approach and reflects further on how to “heal the catastrophising mind”. He also mentions Compassion-focused therapy (CFT) and the work of Paul Gilbert.
Living with depression
The author returns to recount his lived experience of depression and what helped him cope and eventually cure the malady. Part of his recovery plan was to email a different friend each week who he hadn’t seen for a while. He’d earlier talked about the burden of ruminating on this condition alone.
He notes that in the UK there were 8 million people living alone in 2018. It’s moving as he describes his movement out of depression and to recollect what he felt like not to have depression.
This would have been a good place to end the book but there is a further section on “Depression and art” where the author talks about being able to read and listen to music as part of his return to a more normal state. He writes about the depression of Samuel Johnson, Robert Burton and tackles the myth of melancholic creativity. He argues that the realm of arts and letters is crucial to understanding depression and looks at the writings of Emily Dickinson and the role of language.
The Epilogue (“The end of depression”) starts by him reporting that “the despair of depression incrementally gave way to mere drabness” and the “attainment of a new normal”. He said it took two attempts to come off the medication and a second series of sessions with the clinical psychologist.
If you are interested in mental health you should explore the possibility of completing a short course to become a Mental Health First Aider Mental health training online and face to face · MHFA England. Or you might explore volunteering to support a mental health charity – see Volunteering as a Trustee with Richmond Borough Mind (kimtasso.com).