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Thursday, 6 July 2017

Drugs alone won't cure the epidemic of depression. We need strategy: Mark Rice-Oxley

In my own odyssey through this valley of shadows I have mulled over three approaches – between them, they offer a pathway to a wider societal cure, writes Mark Rice-Oxley, the author of Underneath the Lemon Tree: A Memoir of Depression and Recovery, for the Guardian

It’s become as inevitable as the rise and rise of global temperatures or the perennial high-water mark of examination grades: another year, another record number of antidepressants dispensed by doctors up and down the country. This is one of those trends that should be both celebrated and castigated in equal measure. Celebrated, because at last we found something that can help some people deal with an insidious, depleting, often ruinous clinical condition. Castigated because if antidepressants are the answer, we’re not asking the right question.

First, the good bit. Contrary to what detractors may say, antidepressants are not addictive and there is no tolerance effect. They are not like benzodiazapines or opioids – you don’t need more and more of them to obtain the same level of relief. Theoretically, you can sit quite comfortably on the same dose for ever, though it should also be noted that there is little research into long-term usage of these medicines. And while it’s true that science still doesn’t quite know how they work, it is clear that they have helped a great number of people, and certainly saved lives.

But, but, but ... They are also overprescribed, the first and often only resort of the busy healthcare professional to deal with the bewildered person sitting in front of them. They don’t work for everyone. They take weeks, even months, to kick in – and the early side-effects can be awful. They should be reserved for cases of moderate to severe depression, but seem to enjoy an ever wider distribution list. And most crucially they treat symptoms, not causes, meaning that sufferers may never properly confront what has made them unwell in the first place – a vital step in order to achieve sustainable recovery.

So what are the alternatives? In my own odyssey through this valley of shadows I have mulled over three approaches.

Pals, not pills
In the dismal, early reaches of clinical depression, the sufferer wants reassurance. They may actually relish the first meetings with the GP, because they think there will be answers. There are none. Even GPs who know plenty about clinical depression have no idea how it will pan out.

The people who do are the ones who’ve been there before. Fellow travellers.

If a register could be established, GPs could prescribe hour-long buddy sessions, rather than pills, where appropriate.


When children go to new schools, they are often paired up with a “buddy”, someone senior who can show them the ropes, tell them what to expect, how to play it all, the dos and don’ts. We need this for newcomers to the dark underworld of depression. We should build, perhaps in partnership with Mind or the Samaritans, a nationwide volunteer system of “buddies”, available, say, for one hour a week to coach new victims through the worst stretches, reassure them that, yes, most people recover, but that it will be very up and down.

That face to face contact, that reassurance, that human interaction would be hugely beneficial to both parties. If a functional register could be established, GPs could prescribe hour-long buddy sessions, rather than pills, where appropriate. I’d be the first to sign up.

Prevention, not cure
We make the case of prevention not cure with other illnesses: don’t smoke, you’ll get cancer. Keep fit – it will do your heart good. Eat well, don’t drink too much, wrap up warm, it’s cold outside, take your coat off, you won’t feel the benefit.

But we’re only starting to realise that the same precautions can work for mental illness. People need to know there is a serious epidemic out there, but that there are a handful of things you can do to mitigate risk: don’t try so hard, lower expectations a little, stop judging yourself, change your relationship with your thoughts. Take proper holidays, nurture your friendships, try not to worry so much about things beyond your control.

Fledgling prevention strategies have popped up in the City and in some schools, but like so much else the UK, it’s piecemeal, ad hoc, patchwork. There is no strategy, no roll-out, no universality – and there is unlikely to be a cohesive plan now that our short-termist political class is preoccupied with problems of their own making.

Back to school
I can’t help but think that this new depression epidemic is partly down to inflated expectations, to untrammelled individualism and the culture of winner takes all. The pressure to “succeed”, the urgency to validate our short lives with obvious and unambiguous “achievement”: show me a good loser and I’ll show you a loser, they say. No, how about show me a winner and I’ll show you someone on the verge of cracking up.

Show me a winner and I’ll show you someone on the verge of cracking up
Of course it starts in schools, in homes, where instead of teaching our children to be flexible easygoing people, agreeable and comfortable in their own skin, we urge them to outperform, to qualify, to succeed, intoxicated by the notion of their future glory, terrified of what “failure” might mean, ignorant that overachievement brings with it very considerable risks too. Instead, we should value effort not achievement, attitude not outcome. So why not add that as a qualitative mark to a set of exam results? Instead of expending huge effort changing them from letters to different letters to numbers. After all, psychological flexibility is the best qualification a young adult could leave school with.

Of course, mental illness takes many forms and there will always be a place for medication (declaration of interest: I have taken antidepressants for several years). But the current “system” clearly doesn’t work, the drugs are just an expensive way of treading water and the costs of properly facing our mental health crisis would bankrupt the NHS several times over. We need new approaches.

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