On ‘medicalisation’ and depression

There has been a lot of chatter over the weekend in mental health/social justice circles about this article by trendy vicar Giles Fraser dismissing SSRIs. It’s part of a distinct category of article which starts with the idea that some unspecified demographic are being incorrectly diagnosed with something deemed to be ‘on the increase’ and extrapolates it to “Everyone”. They are very common to debates about both mental health and neurodivergent conditions (such as dyslexia, dyspraxia and ADHD, which Giles helpfully mentions). If you like, they’re the middle-class equivalent of the welfare ranters who say we should stop all disability benefit because their cousin’s brother’s mate once saw this bloke who’s on Incapacity down the pub breakdancing.

To be fair to him for a moment, I can understand some of the basic sentiments he seems to be trying to get at. I agree that sections of business and the media give us an ideal (basically white, straight, married with 2.4 kids, size 10, extroverted and wealthy) which we must live up to or else be deemed inadequate and ‘cured’, and that this is a bad thing. I can appreciate there are problems with clinicians sometimes not seeing the wider picture and medicalising a personality trait that’s actually due to another underlying medical or situational problem (three years before being identified as dyspraxic I was given beta blockers for situational anxiety. I can’t even remember any effects let alone whether those were good or bad effects). I agree that drugs aren’t an automatic fix-all and should always be accompanied by talking therapy (which should always be made available *prods legislators*) . And I agree there is a problem with facetious/throwaway misuse of medical terms (my pet hates are: “I think he’s slightly OCD…” or I’m a bit dyslexic”. Would you say “I think he’s slightly got kidney disease” or “I have a bit of chlamydia?”)

However, the problem with the argument that we medicalise ordinary sadness is who or what defines ‘ordinary’. On the surface, we’re all ordinary, it’s what lays below that’s important. The stigma attached to illness, and particularly mental illness (and for those of us who aren’t wealthy columnists, there is still a stigma) means we tend to play down symptoms. Ask any GP and they’ll tell you about someone who’s entered the surgery timidly saying they’re “just a bit under the weather” and “under the weather” turned out to be something serious, even fatal (when I was in the sixth-form, a friend-of-a-friend who went to the doctor with “Freshers Flu” died of leukaemia three weeks later…). In the same way, so-called “ordinary sadness” can cover something a lot more profound. Take being single for instance. While it’s perfectly “ordinary” in itself, in my first and second-hand experience, most people who are always single, whether by choice or lamentably, have big underlying problems in life. And if someone goes for counselling after a two-week fling has broken up or their cat has died it’s probably not because they’re a silly sap, it’s because something a lot more serious is going on in there.

Self-diagnosis is often seen as evidence of over diagnosis. A referral or a self-diagnosis is not the same as a diagnosis. I could claim my account has a million pounds in it but my bank manager would staunchly tell you otherwise and my saying it doesn’t mean there’s been an increase in blonde 29-year-old millionaires whose names begin with M. When people complain about ‘over-diagnosis’ what they often really mean is increased awareness. Yes, there is some consensus over ADHD being over-diagnosed in American children, but a) here isn’t America and b) for every over-diagnosed child there is an undiagnosed child.  If increased awareness means there is some over-diagnosis, frankly, I’ll take that over people who need support to lead contended and productive lives not getting it.

The way I’ve come to see depression (OK, I’m unqualified but no more so than Giles) is a bit like the relationship around metabolism and weight. We have some sort of genetic disposition to it and environmental factors can add to or detract from that. Just as some people can eat a lot and hardly put on weight while others have to watch the calories, and the availability of food underpins that, some people can go through all levels of hell and be relatively unscathed while others can feel knocked for six by a single setback, or even for no particular reason at all. It’s nothing to do with morality or will, it just is. And sometimes when you are knocked for six, drugs become necessary just for functioning. I didn’t hop out of the womb thinking “Woo, I need some SSRIs”, and “There’s something wrong with me” (even though, as I was three months premature, it was a fair bet that there was). I carried on living life as normally as possible until my degree was under threat because I was a virtually nocturnal chronic procrastinator who couldn’t open a book without bursting into tears, at which point I was prescribed a six-month course of Citalopram to get me through. Contrary to what that irritating nickname ‘happy pills’ implies, SSRIs are not recreational drugs – they are drugs you take to feel normal. I couldn’t put it better than a quote from this post:

“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.”

Medicalisation is a bad thing. Under-diagnosis is not a better thing.

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