Dealing with Major Depression: Managing Malignant Sadness

(Talk given to the Existentialist Society, Melbourne, on 2 June 2015.)

This talk is a revised and expanded version of one I gave in January 2013 to the Melbourne Unitarian Church; and that in turn was based on an article I first wrote in 2003.

Please note that I am not a psychologist or psychiatrist, but just someone whose life has been profoundly affected by depression. So although I know a fair amount about my own depression, this does not mean that I can speak with authority about other people's depression. Indeed, my experiences have taught me that, where depression is concerned, what is right or wrong for one person may be wrong or right for another.

I am presenting a personal or anecdotal account of clinical or major depression, also called major depressive disorder, recurrent depressive disorder, unipolar depression and unipolar disorder.

I must stress that I am not talking about reasonable levels of grief, low morale and sadness, which affect almost everyone from time to time, but about an intrusive and often disabling mood disorder: severe melancholia, often accompanied by anxiety, fatigue or agitation, despair, feeling overwhelmed or helpless, social withdrawal or finding the company of others difficult, inability to enjoy life, increased sleep or else premature waking, and either loss of appetite or increased desire for food and comfort. The sufferer may also wish he or she were dead. The embryologist Professor Lewis Wolpert has called it, very appropriately in my opinion, malignant sadness.

I do not intend to talk about manic depression, also termed bipolar disorder, as I know very little about it. Indeed, I am not sure I have
knowingly talked to anyone who has suffered from it. Also, please bear in mind that my knowledge of depression is unlikely to
be up to date.

It is very hard to be sure of details, but women seem to suffer from depression more often than men, although this may partly or wholly be
because women seek treatment more readily than men. For Australia I have come across figures of 4 per cent and 6 per cent of the population suffering from a depressive disorder each year. If I take a middle figure of 5 per cent, and the estimate of Australia's population in May 2015 of 23.8 million, this means that 1.2 million people in this country will be depressed this year.

Depression is also one of the major reasons for suicide, of very roughly a half of people who kill themselves. Other reasons include bipolar
disorder, psychosis, especially schizophrenia, anorexia nervosa and substance abuse.

In Australia, the average number of suicide deaths for 2009 to 2013 was 2461 a year. In 2013 suicides in Australia totalled 2522, but of these, 75 per cent (1885) were male and only 25 per cent (637) were female.

According to the writer and broadcaster Maria Prendergast, "The World Health Organization . . . reports that depression is the fourth most
significant cause of suffering and disability worldwide (behind heart disease, cancer and traffic accidents), and predicts that by 2020 it will be the leading cause of disability in the developed world."1

I was first diagnosed with depression in 1962, at the age of 18, but I was often deeply unhappy and maybe depressed at times during the previous ten years. I have had to endure depression, for varying lengths of time, for fifty years; and it has thwarted my more important ambitions, hopes and plans. You could say that it is a short straw I have drawn in the lottery of life.

Causes

The exact mechanism or cause of depression is open to dispute, and some writers claim it is unknown or unknowable. The novelist and essayist, William Styron (1925 - 2006), writing in 1991, said: "I shall never learn what 'caused' my depression, as no one will ever learn about their own. To be able to do so will likely forever prove to be an impossibility, so complex are the intermingled factors of abnormal chemistry, behavior and genetics."2

Five years later, the sociologist Professor David Karp wrote: "As I see it, efforts to authoritatively uncover the causes of depression are doomed to failure."3

Some people assume that severe depression, especially if recurrent, is a sign of an abusive or dysfunctional childhood. But opinions on this matter seem to vary. The psychiatrist Margaret Reinhold, probably writing in the 1980s, claimed that "As to the causes of depressive illness, . . . we must turn to childhood and parent-child relationships. I can't remember having seen any patient suffering from this illness who hadn't experienced some form of rejection from parents as a small child."4

On the other hand, the American psychologist, Professor Martin Seligman, wrote in 1994: "If you want to blame your parents for your own adult problems, you are entitled to blame the genes they gave you, but you are not entitled - by any facts I know - to blame the way they treated you."5

Professor of psychology Raymond Cochrane, speaking in 1995, said that "Victims of child abuse are at least twice as likely to suffer clinical
depression in adulthood as non-victims", and he added: "Up to 70% of depressed patients admitted to hospitals have been abused as children."6

My own view is that people who have had unhappy childhoods, and that certainly includes me, are more prone to depression and other problems, but they do not all suffer from depression by any means.

On the other hand, some people who have had normal or happy childhoods may become depressed. The Huxley family does not seem to have been dysfunctional or abusive, but Thomas Henry Huxley suffered from depression, as did his grandson Sir Julian Huxley. Julian's brother Trevenen was a depressive, and committed suicide in 1914; and one of T. H. Huxley's daughters, if I remember correctly, had severe post-partum depression.

I share the view that susceptibility to clinical depression seems to be a mixture of genetics and experience. In other words, people with a genetic predisposition react to significant events, such as stress, by becoming depressed, whereas others would become angry, anxious or tired, or would be adaptable enough to cope. And enough stress, such as being tortured or held hostage for a long time, will often trigger depression in all but the most robust of people.

I have come across the suggestion that the genetic element may work in two ways: in favourable or encouraging circumstances it might make the person with the trait more creative or socially skilled; but in adverse conditions the trait may lead to depression.

One theory is that in depressives the two small, almond-like bodies in the brain, the amygdalae, instruct the adrenal glands to produce too much of the stress hormone cortisol. This prevents each hippocampus of the brain from producing enough neurotransmitters called monoamines, such as dopamine, epinephrine, norepinephrine, melatonin and serotonin, and this unbalanced mix of too much cortisol and not enough monoamines interferes with nerve development and connexions in the hippocampi and frontal lobes, and may stop or retard the formation of new nerve cells, giving rise to depressive symptoms. Some depressives have indeed been found to have brains with
enlarged amygdalae and smaller than normal hippocampi.7

The theory offers an explanation of why, when they work, antidepressant drugs usually take ten to twenty days to show any benefit, because they are thought to permit the growth of new nerve cells and nerve connexions. With time the theory may need revising or even discarding, but it seems more plausible than claims that depression has, for some mysterious reason, a cause that is unfathomable or unknowable.

There might also be an epigenetic link to depression. Epigenetics refers to the way in which environmental factors effect not what a gene is coded to do, but whether it is activated or not and to what extent it is expressed. It is a bit like an on-off and volume control. I do not want to bog you down with definitions, so I will give you an example. If after three days honey bee larvae are fed on pollen and nectar, they develop into worker bees; and if the larvae are fed on royal jelly, they develop into queens. But both the workers and queens have essentially the same genetic code.

In a talk in October 2012 to South Place Ethical Society, London, molecular biologist Dr Nessa Carey, author of The Epigenetics Revolution
(2011), explained that if baby rats get a lot of licking and grooming from their mothers, the young grow up into "chilled-out adults who aren't that bothered by mildly stressful stimuli". She added: "But if the babies are raised by females who are stingy with the licking and grooming, they grow up into highly stressed individuals, reacting disproportionately in response to mild stimuli."

The brains of the adult rats were found to differ significantly, as Dr Carey explained: "Certain key genes which encoded proteins involved in the fight-or-flight response to stress were expressed differently, depending on the upbringing of the rat. Specifically, the 'unloved' babies expressed the fight-or-flight genes more highly as adults than the animals who had been nurtured. Essentially, their baseline background stress levels were much higher than normal."8

So there may be an epigenetic explanation of or factor in at least some forms of chronic depression.

And I think William Styron showed insight into many, though I suspect not all, instances of depression when he wrote: "Much obviously remains to be learned . . . but . . . one psychological element has been established beyond reasonable doubt, and that is the concept of loss. Loss in all of its manifestations is the touchstone of depression - in the progress of the disease and, most likely, in its origin."9

The American psychoanalyst Erik Erikson attributed to Sigmund Freud the saying that what was needed for emotional health was Arbeiten und Lieben, to work and to love, but implying satisfying work or creative interests and sustaining intimate ties of various sorts. I think the concept of work and creativity combined with connectedness in various forms, with adequate time and opportunity for both, is profoundly important.

Connectedness certainly seems a protective factor against depression. People with loving, helpful parents are less likely to be depressed that those from dysfunctional families; those who are happily married are less likely to suffer depression than those whose marriages or partnerships are stressful, or those who live alone.

Depression & religion

At this stage some of you may like to know if there is any correlation between depression and religious beliefs.

Well, religion can be form of strong connectedness; but it may also be strongly dysfunctional. Accurate statistics seem rather elusive; but
strongly held beliefs and opinions, whether rational or irrational, often provide some protection from depression. Diehard communists are less likely to be depressed than those with no strong views on politics; committed churchgoers are less likely to be depressed than wishy-washy cultural or nominal Christians or the people recently dubbed as "apatheists". I would also expect staunch atheists to be less likely to be depressed, but I am proof that a militant atheist can also be depressed.

Lewis Wolpert mentions a study in the United States of people aged over 65 which showed that "frequent churchgoers were about half as likely to be depressed, and a Dutch study found lower rates of depression among those who were involved in a religion." He added: "But there are also indications that failure to attend religious services increased the depressive symptoms of believers, and this was true for a number of religious groups, particularly Catholics."

Professor Wolpert mentions another United States study which showed that "Jews had a higher rate of depression than Catholics, Protestants and other non-Jews. The male-female ratio for Jews was most unusual, there being no difference between the sexes, and there is some evidence, somewhat puzzlingly, that this is due to a low rate of alcoholism among Jews."

He adds: "Among Christian groups, Pentecostals had almost twice the rates for depression compared to the others. And another surprise is that the Old Order Amish in the USA, who practise absolute pacifism and lead a life free of hostility and aggression, have a threefold higher than average rate of depression"10

I have come across occasional references to a link between depression and heart disease, though the connexion may be indirect rather than direct.

Depression is often thought to be triggered by stress, and depression itself is very stressful. Some depressives appear to have had childhoods that were more stressful than normal. Chronic stress is also given as a factor in heart disease. Whatever the nature of the link between depression and heart disease, this is grounds for not neglecting depression.

We do not know for certain whether major depression is a single mood disorder or a group or cluster of disorders with similar symptoms. Back in the 1960s people used to talk of reactive or exogenous depression, where there seemed to be an obvious cause or trigger, and endogenous depression, where someone became deeply depressed for no obvious reason. I have always been wary of these classifications, as causes or triggers might not be what they seem; and depression may require a combination of factors to appear.

However, I think we can be confident about the condition known as seasonal affective disorder (or SAD), where someone characteristically
becomes depressed or almost so during the winter months. This does seem to be connected with day length, though again there may be an element of genetic predisposition.

There is also post-partum or postnatal depression in women. This may well be set off by changes in hormone levels after giving birth, but I would not rule out a genetic component as well.

I am happier with the symptom classifications of typical and atypical depression because I have personal experience of them. Depression with typical symptoms includes melancholia, anxiety, helplessness, premature waking in the morning and reduced appetite for food. Atypical symptoms include wanting more sleep rather than waking earlier than normal, and, in particular, increased desire for food and sometimes a craving for sweet foods.

I always had atypical symptoms when I was depressed from 1962 to 2007, and the food craving was very marked. I would sometimes put on a lot of weight, and do my best to lose weight when feeling a bit better. In late 2008, however, I was surprised to find I had typical symptoms. I would wake up too early, my desire for food was reduced, and there was a greater anxiety component. I cannot explain the sudden and permanent change, and can only assume it had something to do with ageing.

Treatment

From time to time I have heard doctors and journalists announce: "The good news about depression is that it is treatable." Everything is
treatable, even terminal illness and death; but what matters is whether treatment is effective. By effective I mean clearly causing considerable improvement that is either long lasting or permanent.

What is rarely mentioned is that between six and fifteen per cent of depressives do not respond effectively to known methods of treatment. I am a very hard-to-treat depressive, but I am not impossible to help. My misfortune, however, was that treatments available in the 1960s and '70s failed to help me or made things worse. I do not think I am being unduly melodramatic or self-pitying when I say that depression has blighted my adult life; but there are others far worse off than me.

I would like to quote a few sentences from an article by comedian and writer Felicity Ward in The Age (Melbourne).9 She wrote:

"Depression can be lots of things. It can be treatable, and liveable, and manageable, and a life surrounded by willing, sup-portive helpers. Many have that experience. But it can also be a slow, noxious, inescapable gas. Or a wolf hiding in the shadows, waiting for your most vulnerable moment to jump - and it will hunt you. And it can kill you. And it is exhausting and relentless and suffocating. Like drowning on dry land."

I know friends who do their very best, who throw everything they have at mental illness or addiction. They sleep enough, eat the right foods, take medication, exercise, practise mindfulness, get help, talk to friends and it's still not enough. Because some-times life is too hard for too long. And for that reason I understand why people suicide. I don't en-courage it. I don't want it to be an answer. But I accept it.11

Psychotherapy

Most mental health professionals regard a limited range of psychotherapies as being beneficial for at least mild or moderate depression.

Over the years I have tried group psychotherapy, Freudian psychoanalysis, Jungian psychoanalysis, albeit briefly, and forms of cognitive therapy twice. Experience of psychoanalysis changed me from true believer to convinced sceptic. I have also tried hypnotherapy twice. There is now a strong consensus that hypnosis is not effective for depression.

From all these forms of therapy I discovered little that was new or of value about my emotions, except and maybe importantly, that I was not paranoid or deluded, and could trust my memory and judgement. But I learned a fair amount about the thinking and preconceptions of psychotherapists. Yes, I was probably very introspective by temperament, but in some instances I was surprised by the therapist's lack of insight or empathy.

A psychologist I saw in 1999 asked me to write down how I hoped my life might differ if I were no longer depressed. On my next visit I produced a careful and detailed list. The therapist looked briefly at the list and remarked dismissively, "It would have been better if, instead of writing 'If I were not depressed I would', you had written 'When I am not depressed I will'."

I realised that this man put a low value on truthfulness; and the more I got to know him, the less trustworthy I found him. He tended to duck issues that mattered to me by saying they were unimportant and refusing to discuss them. He was full of easy slogans and facile promises that lacked substance: his methods were "all gong, no dinner"! I got worse towards the end of the sessions and, after I stopped them, regretted that I had ever seen him.

Drug therapy

Writers and speakers on depression often claim that certain types of psychotherapy, particularly cognitive behavioural therapy, will help about 60 per cent of patients, and that a specific antidepressant drug will also have about the same rate of effectiveness.

Antidepressant drugs have helped and can help very many people, but drugs may also do harm. I went without treatment for years because of doctors who doled out tricyclic antidepressants to me. Tricyclics were the first class of antidepressants to be widely used.12 The worst hell I know is severe depression compounded by the sedation caused by tricyclic drugs. As I learned fairly recently, people with atypical symptoms do not respond well to tricyclic medications. Other antidepressants can cause anxiety, impaired balance, sexual malfunctioning and raised blood pressure. But of course this does not mean that antidepressant drugs are not worth trying.

I first saw a psychiatrist in 1962, but the first time any treatment really helped me was in 1996, when I asked to try a particular drug because it had a side-effect profile I reckoned I could tolerate. I did not expect it to work but, to my very considerable surprise, after just over a week it raised my mood, but only for about six weeks, and then packed up rapidly. A second medication worked for about as long, but not nearly as well, and eventually did not work at all. Later on I found two more drugs13 that were as good as the first, and lasted longer, but after a few months they too packed up or "dropped out", but not for good. When a drug "dropped out", if I stayed off it for about six months, there was a good chance it would work again, but not permanently, of course.

In 2006 the psychiatrist who was treating me tried giving me two antidepressants at once, but none of these mixtures worked. At the end of 2010, however, I found that the three drugs I had relied on for years were no longer working, and nor was any other antidepressant available in Australia. I had lived in fear of just this problem for years, and I was now in trouble. My psychiatrist had retired, and was in poor health.

It took quite a while to find a psychiatrist to treat me, but in August 2011 I saw one who told me she was no good at psychotherapy but she knew a thing or two about "chemicals". She looked at the records I had kept and suggested I take two drugs I had not yet taken combined, mirtazapine, one of the three drugs I had relied on in the past, but now did not work, and venlafaxine, which had not worked and which belonged to a class of antidepressants none of which had ever worked on me. She informed me that, across the Pacific, this mixture was called "Californian rocket fuel".

I was dubious, to put it mildly, but I had nothing to lose.

It took a while to get the doses right, but the mixture not only worked: it did so within hours, not days or weeks; and, to my utter astonishment, it stayed working: the mixture did not pack up after a few weeks or months. All of this was quite different from what I had come to expect from single antidepressants, and, as my G.P. pointed out, it is a good example of synergy: two things combined having properties more than the sum of their individual properties.

There has been interest recently in ketamine, normally used in anaesthesia and pain management, as a possible fast-operating
antidepressant. It has not been approved in Australia for depression, as not enough clinical trials have been done. It seems to work quickly, for not for long, and has a number of unpleasant side effects in some people; but a derivative of it may yet prove helpful for major depression.

Electroconvulsive therapy

Electroconvulsive therapy (E.C.T.) rarely gets a mention nowadays. This is probably because it was overused, misused and grossly abused in the past for treating depression and a number of other illnesses. It is now used very sparingly, under careful supervision, for certain types of drug-resistant depression, especially catatonic depression, and a qualified anaesthetist has to be present. It does work on some chronic and severe depressives, and can make a great difference to their quality of life.

I tried a course of E.C.T. in 2002. It did not reduce my depression, and it caused short-term memory loss and periods of anxiety. The memory loss was sometimes rather farcical, occasionally a bit scary. However, I am glad I was given the chance to try E.C.T.

Repetitive transcranial magnetic stimulation

There is a fairly new method of treatment I have not tried. It is called repetitive transcranial magnetic stimulation, abbreviated to R.T.M.S. It
involves delivering magnetic pulses to the frontal lobe of the brain for about 25 minutes. This is done by placing a coil, shaped like a figure
eight, over the front area of the scalp. The procedure is repeated about twenty times at regular intervals, and is reported to help 35 per cent of adults who have not responded to other treatments. Unlike E.C.T., patients having R.T.M.S. do not need to be anaesthetised; in fact they can drive home afterwards.14 But transcranial magnetic stimulation is not given to depressed people with epilepsy in case it triggers seizures or fits.

Exercise and alcohol

Exercise is often recommended as very good for depression. In my case, however, it nearly always had the opposite effect: it increased suicidal feelings, often markedly, because when exercising I could not normally occupy my mind. The things that have helped me, when very depressed, were, besides emotional support, writing, reading, or watching something engrossing on television. The last three are partial anodynes or escapes and, of course, as soon as I stopped doing them I was fully aware again of the depression.

In late 2004 a friend told me that, while listening to the radio, she had heard a report about recent research on exercise and depression. The gist of the report was that, although regular exercise could be beneficial for people with mild depression, exercise was often useless or
counterproductive in cases of major depression. This seems to corroborate my experience that exercise made me feel worse, or even much worse, when I was depressed. In fact wanting exercise or being able to enjoy it was a reliablesign that my depression levels had become very low.

Mental health professionals regularly warn against the use of alcohol as a form of self-medication for depression. Alcohol may give brief and partial relief from depression, but it certainly does not "fix" depression; and I am sure that alcohol abuse will exacerbate any mood disorder or mental illness.

I am aware of the risks of using alcohol too freely, and I decided when I started driving regularly, in 1981, not to drink alcohol earlier than 5:30 p.m., even on Christmas Day.

If my memory is reliable I can think of perhaps a couple of occasions when moderate alcohol use might have stopped me attempting suicide, by making me relaxed and sleepy, and dampening down suicidal thoughts. However, I suspect alcohol may well have the opposite effect on some people with depression.

As I mentioned at the start of this talk, if I have learned nothing else in the last fifty years, it is that what helps one person with depression
may be useless or downright harmful for someone else.

I have also learnt that congenial work or creative activity usually correlates with low levels of depression, and unemployment and uncongenial work are linked with high levels of depression. But depression has, of course, markedly limited my employment prospects, so I have at times been in something of a vicious circle.

Even as a young man I realised that, unless I could get my depression really under control, my life would be stunted. So I spent a lot of effort, time and money both on treatment and self-help measures, like major changes of lifestyle, but the results were often rather poor. Motivation may be necessary for success, but it does not guarantee it.

Bad experiences . . .

I have been unimpressed with a significant minority of mental health professionals I have encountered over the years. One psychiatrist in 1966 kept me waiting for seven months for group psychotherapy, despite my saying I doubted if it would work because I would feel inhibited in a group.

Another psychiatrist told me I did not look very depressed as I was wearing my best suit. I had some cousins' party to attend afterwards, but I had been feeling suicidal for months. A third psychiatrist decided I had "existential" depression.

In 1996 a doctor at a Victorian regional psychiatric hospital gave me a narrow and grossly misleading definition of depression in an attempt, I presume, to convince me I was not really depressed. The chief nurse at the same hospital told me how little regard he had for most of the patients because he believed they had made themselves psychotic through excessive use of cannabis. This fellow had probably not stopped to ask himself why people might abuse cannabis to this extent. (I have never been psychotic and I have
never used cannabis.)

I have a report on file by a young psychiatric nurse who wrote in 1997 that she did not believe I was suffering from a depressive illness and "it is not surprising that antidepressant therapy has had minimal to nil positive effect on him to date". The next year (1998) I was referred to an eminent specialist psychiatrist in Melbourne who diagnosed that I had moderate to severe chronic major depression.

In late 2010 I had the misfortune to be referred to a psychiatrist who spent more than twenty minutes of the eighty-minute consultation in a digression on modern art. At times I felt he was barely listening to me. This was borne out by the report sent to my G.P., whom I had already warned.

The report said that "On interview today, he was a long haired, articulate man, who appeared intelligent. . . . Unfortunately, he has intellectualised his medical treatment over the years and has developed a belief that changing his anti-depressant every six months has kept him well." I had of course said nothing of the kind.

The report then stated: "He is convinced that he will be requiring a change in anti-depressants soon and feels that moclobemide would be the safest option." Er, no. My G.P. had referred me to the psychiatrist because the three antidepressants he and I had been able to rely on in the past, including moclobemide, were no longer helping me, and I had clearly said so as well.

On the other hand I have been impressed with books on depression by people who have suffered from it, particularly David Karp's Speaking of Sadness (1996), William Styron's Darkness Visible (1991) and Lewis Wolpert's Malignant Sadness (1999). Professor Karp discovered that people with chronic depression in the United States did not usually get better: they went from professional to professional, looking for "the right one", and finally - gave up! I have probably learnt almost as much about depression from writers who have had it as from people who claim they can fix it.

I would like to quote a few words from William Styron: "Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self - to the mediating intellect - as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode . . ."15

Elsewhere in the book Styron says: "The most honest authorities face up square to the fact that serious depression is not readily treatable. . . . Those that do claim an easy way out are glib and most likely fraudulent."16

Not all writers about depression are kind about it. The best example of what I mean comes from a book published in 1973 and 1975, The Denial of Death, by cultural anthropologist Ernest Becker (1924-74), who clearly thought depressives were a gutless lot:

"Adler . . . revealed how perfectly depression or melancholia is a problem of courage; how it develops in people who are afraid of life, who have given up any semblance of independent development and have been totally immersed in the acts and the aid of others. They have lived lives of 'systematic self-restriction,' and the result is that the less you do the less you can do, the more helpless and dependent you become. . . . If one's life has been a series of 'silent retreats,' one ends up firmly wedged into a corner and has nowhere else to retreat. This state is the bogging-down of depression. Fear of life leads to excessive fear of death. . . . Finally, one doesn't dare to move - the patient lies in bed for days on end, not eating, letting the housework pile up, fouling the bed.

"The moral of this example of failure of courage is that in some way one must pay with life and consent daily to die, to give oneself up to the
risks and dangers of the world, allow oneself to be engulfed and used up. Otherwise one ends up as though dead in trying to avoid life and death. This is how modern existentialist psychiatrists understand depression, exactly as Adler did at the beginning of this century."17

Becker's verbiage strikes me as contempt and disgust masquerading as psychology, or bigotry disguised as courage. It is also, if my experiences are anything to go by, utterly dishonest. And since when did depressives in general have an "excessive fear of death"? I suggest we all give "existential" psychiatrists a very wide berth!

One writer on depression I treat with caution is the Australian born, British based clinical psychologist, Dr Dorothy Rowe. Her interpretation of depression is that is a home-made mental cage into which people put themselves and from which she can release them, if they really want to be released. She is perhaps best known for her book Depression: The Way out of Your Prison, first published in 1983.

I do not discount everything that Dorothy Rowe writes and says, for example her scepticism about cognitive behavioural therapy and her advocacy of freedom, love and hope if we are to live fully; but her notion of depression as a self-made prison strikes me first as patronising and secondly, even though she is non-religious, as something akin to a rebranding of the Christian notion of sin. To quote from her book:

"Pride, so Christian theology teaches, is the deadliest of the seven sins since it prevents the person from recognising his sins and repenting
and reforming. Sin or not, it is pride that keeps you locked in the prison of depression. It is pride that prevents you from changing and finding your way out of the prison."18

And no doubt disagreeing with Dorothy Rowe is "pride" as well! But her vainglorious attitude towards depressives strikes me as a clear case of hubris, which is arrogant pride and presumption.

I do not agree that depression is necessarily caused by false perceptions and opinions; but false perceptions, such as that one is
worthless, may certainly exacerbate depression or may even be a symptom of depression rather than a cause. I see depression as a disorder that is visited upon sufferers by genetics or environment or a synergistic combination of both; but sufferers are at least free to wish not be depressed.

When Dorothy Rowe was in Australia in 2006, she wrote an article in The Age or the Sunday Age, trotting out her usual "prison" concept. I was not surprised that the article generated several letters accusing her of maligning people with depression.

May I caution people who have depression and other mood or emotional problems, especially if they are non-religious, about Grow, which calls itself a "world community mental health movement". It was based on the methods of Alcoholics Anonymous, and was founded in Sydney in 1957, with the original name of Recovery, by Fr Cornelius Keough. It has spread to other countries such as Britain, Canada, Ireland, Mauritius, New Zealand and the United States. It claims to be "anonymous, non-denominational and open to all", and offers as its remedy for mental health problems, "Truth, character and friendship". It claims "The only person who cannot be helped by Grow is the man or woman who is in real need and does not know it, or will not admit it."

If you turn up to a Grow meeting, however, you will be expected to subscribe to stuff such as "We enter the way of growthful change by making the humble admission: 'I am inadequate or maladjusted to life'." And we are told that "These words can be understood to mean mentally and/or socially and/or spiritually out of tune with reality." Furthermore: "Inadequate means either immature or insufficient on my own".

Well, not everyone with a mood disorder is immature; and I do not think people are "inadequate" if they are "insufficient" on their own. Loners are "sufficient" on their own; but for good mental health most people need connectedness: sustaining and rewarding emotional ties with others.

Under Grow's "12 stages of decline and maladjustment", number two is "We grew inattentive to God's presence and providence and God's natural order in our lives"; and "The 12 steps of recovery and personal growth" include number three: "We surrendered to the healing power of a wise and loving God".

Grow does say that unbelievers are welcome at its meetings and, I quote: "unbelievers are never expected to join in the closing Prayer for Maturity or any other spiritual expression of Growers". It also offers "a special formulation of all basic parts of the Grow Program which unbelievers may comfortably say".19 But I suspect that most Grow groups have the standard wording. A Grow group in the western suburbs of Melbourne that I visited twice some years ago was run by the wife of a Presbyterian minister. Its advertising on notice boards never mentioned its strong theistic overtones.

In 2003, with the help and encouragement of my then psychiatrist and later friend, Dr Philip Wood (1934 - 2012), I wrote an article, "Existing with Depression". I submitted it to The Skeptic, magazine of the Australian Skeptics, and it was published in December 2003. A year later I added to it in the form of a published letter. The text of the article and letter, with a few additions, formed my contribution to Chapter 7 of Maria Prendergast's book, Understanding Depression, published by Penguin Australia in 2006.

When "Existing with Depression" first appeared in print, I imagined it would attract a bit of comment and very probably adverse criticism. To my considerable surprise, e-mail messages kept coming in to me about it for more than a year. I received several times more feedback about this one article than about everything else of mine ever published put together. I was particularly astonished that all the comments on the article were complimentary.

Finally, what can I say to other people with depression? First, beware of those who talk about "beating", "conquering" or particularly "curing"
depression. You may be fortunate in having a single bout of depression from which you make a complete and lasting recovery; but for many sufferers depression recurs or, in varying degrees, persists. It can quickly turn living into just a burdensome existence, as can arthritis, a medical condition by analogy with which depression has been compared by some writers. So seek methods to lighten the burden. You may or may not be able to shed the burden entirely, but living with a lightened burden is better than a needlessly burdensome existence.

I know what it is like to feel suicidal for years on end. I also know how it felt to try - unsuccessfully - to prevent someone I cared about, my
maternal grandmother, from committing suicide. Yes, you have the right to commit suicide, but doing so without trying a range of treatments for depression is a needless waste of your life. Treatment may help not only you; it may indirectly help others, such as the people you live with or other depressives. Even if you cannot reduce your depression below intolerable levels, please remember that clumsy attempts at suicide can make things very much worse. If you jump off a building, you may still be alive at the bottom - but in a wheelchair for the rest of your life.

Seek help from professionals who are trustworthy. Professionals who give you just the "good" news, who lie to you, or who persist in treatments that are endlessly drawn out, without any benefit, or that make you worse, are not worth bothering with. If your psychiatrist or psychologist behaves like a bombastic creep, trust your own judgement - yes, this is sometimes very hard when you are miserable, withdrawn and desperate - and try to find someone else who is better!

Remember that even the best professionals are fallible. A good psychiatrist may try you on a drug that makes you worse simply because it is often hard to predict reliably how a drug will affect you. If the side effects are unbearable or clearly dangerous, and you are often the best
judge of this, stop taking the medication. If they are unpleasant but bearable, put up with the drug for a reasonable period and, if things do not improve, ask for the drug to be changed or stopped. A good professional will accept this; a bad one will say you have not tried long enough, or that the drug or treatment helps "everybody".

If you get the chance, talk to other people who have, or have had, depression. They may help you put your own problems into perspective, and they may be able to give you useful advice. Remember, however, that what is right for someone else may not be appropriate for you.

If you find you have recurrent depression, make sure you keep your own permanent and accurate record of treatments, including medication doses, and their effects on you.

Finally, beware of the notion that you deserve to be depressed: that you must have done something wrong to be depressed, or that depression is some sort of cosmic punishment. Never trust anyone who says, "Oh, snap out of it!" or "It's all your own fault!". Nobody volunteers for depression, nor are people depressed because they are in some way unworthy of happiness. Look around, and you will occasionally find on the one hand cruel, greedy scoundrels who seem to live happy, prosperous lives without a moment of depression, and on the other hand good, kind, generous people whose lives are blighted by bereavement, disability, disease or early death.

In the real world horrible and unfair things often happen to good people. Having depression is a grave misfortune but, once you realise you
are depressed, you do not have to be fatalistic and do nothing about seeking help.

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1 Prendergast, Maria, 2006; Understanding Depression (Camberwell, Vic.: Penguin): 3.
2 Styron, William, 1991; Darkness Visible: a memoir of madness (London): 38.
3 Karp, David A., 1996; Speaking of Sadness; depression, disconnection and the meaning of illness (New York): 14.
4 Reinhold, Margaret, 1991; How to Survive in Spite of Your Parents (2nd edn. London: Cedar/Mandarin): 194.
5 Seligman, Martin E. P., 1994; What You Can Change and What You Can't (Sydney): 232.
6 Cochrane, 1995, "Women and Madness"; Ethical Record (London), 100 (6), June: 12 - 17.
7 Farley, Peter, 2004: "The Anatomy of Despair"; New Scientist, 182 (2445), 1 May: 43 - 45.
8 Carey, Nessa, 2012: "Epigenetics: The missing link in the nature/nurture dichotomy?" Ethical Record (London), 117 (10), Nov.: 14 - 16.
According to Nessa Carey, "These differences in gene expression . . . had nothing to do with the genetic code. This was identical in both experimental groups. They were caused by differences in small chemical modifications to the DNA of the relevant genes. These are known as epigenetic modifications and they don't change what the genes code for. Instead, they influence how highly genes are switched on . . . In the neglected rats, these modifications to the brain cells were established early in life when the rat baby was having a really stressful time. But then the modifications got stuck, and the animals' brains were locked into a particular pattern of gene expression even when they were adults."
9 Darkness Visible: 38.
10 Wolpert, Lewis, 1999; Malignant Sadness: the anatomy of depression (London): 59 - 60.
11 Ward, Felicity, 2014; "We Can All Act on the Black Dog". The Age (Melbourne), August 15: 29.
12 Besides tricyclics (TCAs), other classes of antidepressants are tetracyclics (TeCAs); monoamine oxidase inhibitors (MAOIs, of which there are various types including irreversible and reversible); serotonin norepinephrine reuptake inhibitors (SNRIs); and selective serotonin reuptake inhibitors (SSRIs). There are others (e.g. NDRIs, NRIs).
13 Moclobemide (MAOI-RIMA), fluoxetine ("Prozac", SSRI), mirtazapine (TeCA) and paroxetine (SSRI), in that order.
14 Medew, Julia, 2014, "Depressed? You Could Soon Be Beaming". Sunday Age (Melbourne), 19 April: 7.
15 Darkness Visible: 7.
16 Darkness Visible: 9 - 10.
17 Becker, Ernest, 1975: The Denial of Death (New York): 210.
18 Rowe, Dorothy, 1983, Depression: The way out of your prison (London: Routledge & Kegan Paul, 3rd imp., 1984): 129.
19 GROW . . . The Program of Growth to Maturity; (revised edn. Enmore, N.S.W.: Grow, 2004 imp.): cover, cover verso, 3, 4, 5, 22 & 23.

I am grateful to Halina Strnad for reading through and commenting on one of the last drafts of this talk.

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Based on an article written in 2003 with additions in 2004 and 2005.

Revised and reworked as a talk, December 2012, January & May 2013, Sept. 2014, May & June 2015. This version: 3 June 2015.