Keep taking the tablets

The Government drugs watchdog says that doctors are over-prescribing antidepressants. Not so, says Virginia Ironside. In a world full of unrealistic expectations, Prozac can be a life-saver

It's a pity that we only have one word for depression - because true, full-blown, suicidal depression bears no relation at all to normal depression, ("Isn't this weather depressing?") or sadness, misery, melancholy or the blues. As anyone who has suffered will know, true depression is another animal, another species. I have often said that I would prefer to suffer from cancer than depression - a sentiment that provokes embarrassed titters of, "Oh, you can't really mean that!", from my friends. But I know cancer patients who want to live. I don't know anyone suffering from depression who doesn't want to die. I would rather be in a war zone suffering agonies as loved ones expired around me, actually experiencing the pain of reality, than sitting in Shepherd's Bush on a cold, wet Sunday trying to persuade myself that an overdose really wouldn't be a good thing.

It's a pity that we only have one word for depression - because true, full-blown, suicidal depression bears no relation at all to normal depression, ("Isn't this weather depressing?") or sadness, misery, melancholy or the blues. As anyone who has suffered will know, true depression is another animal, another species. I have often said that I would prefer to suffer from cancer than depression - a sentiment that provokes embarrassed titters of, "Oh, you can't really mean that!", from my friends. But I know cancer patients who want to live. I don't know anyone suffering from depression who doesn't want to die. I would rather be in a war zone suffering agonies as loved ones expired around me, actually experiencing the pain of reality, than sitting in Shepherd's Bush on a cold, wet Sunday trying to persuade myself that an overdose really wouldn't be a good thing.

This is why the argument about the over-prescription of Selective Serotonin Reuptake Inhibitors (SSRIs) is such a knotty one. On the one hand there is the point made last week, by the Medicines and Healthcare Products Regulatory Agency, that antidepressants should be prescribed with greater caution by GPs to those suffering from mild depression, like bereavement or job loss or divorce, because of the small - but crucial - risks associated with them for some people. We have all heard stories of young people who, after just one panic attack, are bunged on SSRIs like Prozac and Seroxat, and spend weeks suffering horrible feelings of going mad. Some, indeed, have actually committed suicide.

On the other hand, there is no doubt at all that antidepressants have saved thousands of people's lives. Whether there is a placebo effect involved is in a way neither here nor there. Who cares? Only the other day I had a phone call from someone who a month before had told me he wanted to die, and now wanted to tell me, after a course of antidepressants, that he had woken that morning to find that life was worth living after all. A veil had been lifted. He was back in the real world. I was given four different types of antidepressant during a four-week stay in The Priory clinic. None worked and I felt terrible. The fifth perked me up within two hours. Looking back, it must have been a placebo effect, but it worked and got me back on track.

Antidepressants are certainly something of a mystery. "The problem is that if you have low blood pressure or a broken leg, this can all be recorded objectively," says Dorothy Rowe, the psychologist author of Depression: The Way out of Your Prison (Routledge). "With depression there is no objective test. You just have to rely on what people tell you. It's interesting that there is no scientific research that shows that any kind of chemical imbalance is responsible for depression. The idea that there is a lowered level of serotonin in the brain when people are depressed is entirely mythical."

But what about the "mild depression" for which antidepressants are so often prescribed? After all, there are whole housing estates in which large percentages of the inhabitants are on Prozac. Are we actually more gloomy than we used to be? Or do we just think we're more gloomy?

It's terribly easy to rustle up reasons why we feel low, generally, at any time in our history. Today we could argue that though we're all more prosperous and live, generally, far easier lives than in the past, the devil does make work for idle hands. The more leisure and unemployment we have, the more isolated we become from one another, the more hopeless we feel. You only have to look at I'm a Celebrity... Get me Out of Here! and hear most of the contestants declaring that, starvation, arguments, hideous challenges notwithstanding, it was the happiest time of their lives, to realise that involvement with other people, pulling as a team, being part of a community, however vicious, makes for fulfilment and fun.

Most people today complain of a feeling of powerlessness, which makes them feel low and frustrated. They have little faith in a government that appears not to listen, and feel that there is no point in protesting about it. Lack of religion creates an empty space in a lot of people's lives, too. I'm no fan of religion, but there's no question that going out once a week with a community of people from different backgrounds, and sitting still together for an hour concentrating on things other than achievement, can't fail to steady the wobbling or fragile personality.

Today, we have many unrealistic expectations of happiness, as well. We are bombarded with television shows that show us that a bigger house, a bit of decking, a cleaner kitchen, a better sex life will bring us rewards and, no less, that this is what we deserve. I had an e-mail from a friend in America, just out from being sectioned recently, and she ended her message with "Peace. Life is good. Enjoy." Total rubbish, of course. Life is not good. Life is sometimes good and sometimes bad. If you set yourself up to believe in happiness, you're bound to be depressed.

The whole present cultural mentality, too - that there is some kind of norm of mental health as opposed to dysfunctionality - is entirely unrealistic. And, on the whole, counsellors don't help, getting their clients to concentrate on the worst aspects of their childhoods, a sure-fire way of feeding depression rather than eliminating it, "ruminating" being one of the symptoms of depression that should not be encouraged. As one who has spent over £54,000 in today's money on therapy, over 12 years, getting increasingly miserable, I should know.

A climate in which we feel that everything is fixable when in fact it is not, is one to make us unhappy. There is some way in which a sense of unrealistic hope can make us depressed, whereas a realistic assessment of a situation as horribly unavoidable may be tough, but at least more easy to cope with.

There is also evidence that people tend to be more open emotionally. Where, in the past, they may have been stiff-upper-lippish about their feelings, they now feel it's OK to admit that they are not always happy.

So, are we really more unhappy or not? Well, we are and we aren't. The odd thing is that, if you look at the adult population as a whole, there is actually no evidence that depression is on the increase. "We are not more depressed than we used to be," says Professor Simon Wessely of the Institute of Psychiatry, part of the Maudsley Hospital in London. "There have been two reports by the Office of National Statistics, one in 1992 and one in 2000, and there has been no change in the prevalence of depression at all. The prevalence of all psychiatric disorders has not altered over the last decade."

But if you look at depression among adolescents, particularly male ones, you see a different story. It's rising fast - and could create a generation of depressed adults in the future. Emotional problems and depression have risen in adolescents by 70 per cent in the last 25 years, according to a report by the Institute of Psychiatry. And it's not, according to Eric Taylor, the professor of child and adolescent psychiatry at the institute, quite the same kind of depression suffered by adults, in that it doesn't respond as well to antidepressants and that it appears to be due less to genetic factors than environmental and social ones. The rise could be partly due to the fact that while in the 1970s, 70 per cent were in work and earning money, today 70 per cent are in dubiously useful further education, with many unable to get the vocational training they need. More than a quarter, at 16, have no prospects of work or training open to them. Rising divorce rates, single-parent families, and the lowering of the age of teenage drinking are also blamed.

"But I think the biggest factor is the increase in drug-taking," says Professor Taylor. "And this big increase of depression in adolescents does raise the possibility that the depression is going to be translated into adult life, implying that there will be a general build-up of depression in the adult population in future."

Depression is, as I know, the worst illness to suffer from in the world. It is clear that there isn't just one way to tackle it, nor, indeed, even 10 or 20 ways to tackle it. For mild depression in people whose depression isn't caused mainly by environmental problems, there are dozens of remedies that doctors could offer - from short-term cognitive therapy (very effective), to fish-oil supplements, exercise, cutting down on alcohol and caffeine, doing relaxation exercises, yoga and voluntary work.

For major depression, the big stuff, the suicide business, people such as Professor Wessely believe that some doctors are actually under-prescribing. On the whole, antidepressants are non-addictive, pretty safe, if properly prescribed, with proper warnings of the side-effects. Even though they can seem to work differently for different people at different times, and can seem for some people to be unreliable, at least you'll know within six weeks whether they are actually working or not. And if they can transform people's lives from total misery to optimism, from wanting to die to wanting to live (or, rather, not wanting to die), then it is surely worth giving them a go.

But as for the growing trend of young depressed adults, ground down by a sense of despair and hopelessness, for whom many of the above remedies would be ludicrous, there is hardly anything on offer. It's a very depressing prospect. And it looks as if it's only going to get worse.

Depression Alliance (0845 123 2320)

AND DID THE DRUGS WORK FOR YOU?

Mandy Williamson, 44, from Exeter, chief executive of Mind

Depression first hit Mandy Williamson in her teens following a bereavement. She was diagnosed when she went to university, and was given medication. During the last 10 years, she has been on antidepressants, including SSRIs, about five times for six-month stretches. She has also had counselling.

But what she has found most useful is a self-help book. "About four or five years ago I came across Mind Over Mood, which was about doing your own cognitive behavioural therapy. I began to work through it and found it incredibly helpful. Part of what it tells you is that it's not just you, and they give you hope that there are ways out of it. It's not something you have to live with all the time. I've had bouts of quite serious depression since, but I have techniques that I can use to get me out of them."

In a scheme being launched next month, GPs in Devon will be referring patients with mild depression to their library and prescribing a self-help book, rather than immediately recommending a drug.

The last time Mandy took medication was three years ago. "I was contemplating taking antidepressants the other day because when I use them, they've worked; Prozac is like a crutch that can lift you and keep you going while you get it sorted out yourself. I don't think it's the answer in itself. The book has been better than drugs in the long term. It helps me even when I'm not depressed, which means less chance of sinking into depression again."

Graham Miller, 54, from London, former assistant manager of an old-people's home

Several months after contracting a virus, Graham Miller became depressed in 1987. He has since also been diagnosed with ME. After having to take so much time off work, including a spell in hospital, he was medically retired eight years later.

He first started taking antidepressants when he was hospitalised for four months in 1994 because he was suicidal. "It was one of the SSRIs. They didn't agree with me. I spent my whole day lying on my bed thinking that I was going to walk down to the river Thames and throw myself off Westminster Bridge, and I had terrible anxiety."

While they didn't have the negative affects of the SSRIs, tricyclic antidepressants did not help lift his depression either. "It was only when I started taking St John's Wort in 1998 as well that I've come to grips with it. I've only had benefits. The depression is more or less under control now. I do get the odd day, but before it would last for weeks."

Graham also finds meditation very beneficial, and takes fish-oil supplements, a herbal mix and vitamin B. "I've tried to wean myself off the antidepressants, but when I do, I experience problems. I get very, very ratty. I'd love not to be taking them. I'm not ready to face the withdrawals yet. I don't know how long they will last. I certainly wish I'd never had anything to do with them."

Jayne Morgan, 29, from Bradford, a former local government officer

After attempting to jump out of a window at work, Jayne Morgan was diagnosed with clinical depression in 1997. She was put on tricyclic antidepressants for two years, but they failed to lift her mood. She then tried SSRIs, including Prozac, but neither did the new type of antidepressants work. "I can't remember how many nervous breakdowns I've had. I've been left with a lot of memory problems, some of which I think is due to the sheer volume of medication that I've been on. I didn't recognise who I was on those tablets, it was scary. If anybody made an off-hand comment at work, I would want to throw a hole-puncher at their head."

Jayne was made redundant in 2002 and has not found work since. In April this year, she stopped taking medication. "I'd got worse and the doctor just doubled the dose of the antidepressant I was on. I couldn't think how they would help me in the condition I was in and couldn't get any lower, so I went cold turkey. In a lot of ways I do feel a lot better now, but that could be because I've had a lot of good experiences this year. I would go back on antidepressants, but only out of desperation. But looking back, if I hadn't had that tiny bit of hope that the tablets might make me better, I might have succeeded with some of the suicide attempts."

Interviews by Julia Stuart