Intended for healthcare professionals

Personal Views Personal views

An insider's guide to depression

BMJ 2001; 323 doi: (Published 27 October 2001) Cite this as: BMJ 2001;323:1011
  1. Kay McKall, general practitioner
  1. Ipswich

    Iwonder if you are as inept and uncomfortable at handling depressed patients as I am. Or as I formerly was, before I found myself the unwilling occupant of a psychiatrist's couch, a couch it seems to me I've barely left in the past five years, apart from comfort stops and cups of tea. Thus did I become the reluctant insider of the title.

    Refuse to see us as the useless rejects that we think we are

    In the course of obtaining this superb basic and advanced training in depression, I've become sensitive to mistakes that other doctors make when managing me, and I have translated those mistakes into corrections in how I myself manage people with depression. The point of this article is to share these with you.

    Although I have bipolar affective disorder, I continue to function successfully as a general practitioner, albeit stuffed to the eyeballs with medication. My partners and a large proportion of my patients know my hideous secret, but I still seem to be here, dishing out amoxicillin with the best of them.

    And my favourite and most rewarding group of patients is people with depression.

    How it feels to be depressed

    People with depression rarely complain about feeling depressed. Is depression really primarily an affective disorder? In my experience, personal and medical, low mood is less reliably present than lack of motivation and interest. Nothing is worthwhile including, eventually, life.

    The bleakness of the landscape is unimaginable. It is as friendless and alien as a Dali painting. Ordinary concerns, such as work or friends, have no place here. Futility muffles thought; time elongates cruelly.

    Who is to blame for this situation? Those with depression think it must be them. Pointlessness and self loathing govern them.

    So the natural final step is suicide. People with depression don't kill themselves to teach their families a lesson or to frighten an errant boyfriend. They kill themselves because it is the obvious and right thing to do at that point. It is the only positive step they can think of.

    How to look after a depressive

    How do you look after “one of us”? Well, for a start, don't expect us to have insight. We don't. We are the last people to give you a balanced account of how we are. When you try to gauge how we're doing, stick to finite questions. How many hours do you sleep? Can you read a book? A magazine article? OK then, the back of a cornflakes packet? Have you laughed? If you ask us simply, “How are you?” we'll tell you that we're OK.

    Don't assume depressed doctors know that they're sick. The view is quite different from this side of the sanity divide. Chances are that we think that we are only stressed by work, and are distressed by our perceived inability to cope.

    People with depression don't have any sense of judgment or proportion. We desperately try to look as if we're in control, and often we don't know ourselves that our perceptions are false and our interpretations distorted. Don't let us make major life decisions.

    Nor do we have a sense of humour. We can recognise humour but only in a detached way, the same way that we can recognise a blackbird. We cannot respond to it. Jokiness on the part of the doctor causes instant alienation. It makes us feel that the doctor either has no understanding of our situation or is embarrassed by it.

    Don't be nervous about being empathetic. We won't clutch at you like drowning men. We want you only as a doctor. Make us feel like worthwhile people with a treatable illness. Refuse to see us as the useless rejects that we think we are.

    Feel free to ask us if we're suicidal. Suicidal thoughts for most of us have become an everyday distress and we're relieved to be able to talk about them. Ask for details. Force us to consider how our suicide would make children, family, and friends feel. Make us promise to keep going a little longer.

    Give us hope. We need to be told unequivocally that we will get better. We can see no end to our situation and no explanation for it—you as the doctor must supply both.

    Most of us will be getting little sleep by the time that we're forced into your consulting room wringing that hanky. To us our waking hours are almost physically painful because of the constant bombardment by negative sad thoughts. Escaping them for a few hours courtesy of a sleeping pill is wonderful.

    When you give us drugs, tell us about common side effects. If you don't do so and we get these side effects, our embryonic sense of hope is badly damaged.

    See us frequently at first. A week is a long time in a Dali landscape. Three weeks are almost unimaginable. Give us a reliable number we can call. This makes us feel that someone sees us as valuable. Inexplicable from our point of view, but nice.

    You will get us better. Just sustain us and give us a focus of hope until the drugs work. And we will forever value you for your humanity.