Episode 14: Understanding depression and anxiety.

When people come to see me suffering with depressed or anxiety, I sometimes ask what they mean by this. Their opening statement might be something like “I need help with my depression, or my mental health”, and I ask what this means to them, what do they think mental illness is?

And often I get back a blank stare, as though I’m trying to mock and dismiss them or am just an idiot. What kind of doctor doesn’t even know what depression is? But I’m not just trying to wind people up, or to be a smart arse. It’s a serious question. We talk about depression and anxiety a lot in our society, but many people, including doctors, nurses and probably even some psychiatrists are not that clear in their own minds what we are actually talking about. Even if we are clear in our own minds, we are certainly not always in agreement with each other.

A central theme of this series is that we are always responsible for our own health, not for any moral reason, but because we are the ones with the most power to influence it, and by a very wide margin. If we are going to be responsible for our own mental health, it is important that we have a clear understanding of what we mean by mental health and mental illness. If we are not clear about this we may struggle to find the most effective strategies for manging our problems, and will run the risk of inadvertently adopting harmful coping mechanisms.

You may not agree with my opinion about the nature of mental health problems at the outset, it is just an opinion, it is not doctrine. But I would like you to at least consider it, and approach it with an open mind. For me this view point is empowering and improves our chances of being able to make positive influences in our own lives, and because of this I think it can be a helpful way of understanding depression and anxiety.

OK, here goes.

Anxiety and depression are not diseases. They are symptoms.

What do I mean by this?

Take pain, for example. It’s a good example because depression and anxiety might be considered to be a form of pain. There is no disease that’s called “pain”. Pain is a symptom, an experience that we feel in our bodies, and has many different causes. The disease is the underlying cause of that symptom.

As we have discussed previously for any one symptom there are hundreds of potential causes. For example tummy pain is a symptom, and this can be caused by various different diseases, such as diverticular disease, and inflammatory bowel disease, or by things that we don’t normally consider to be diseases at all, like trapped wind.

Anxiety and depression are the same. They are symptoms, and there are probably thousands of different underlying causes or diseases that can produce these symptoms. I say probably because our understanding of these conditions is very limited in comparison to our understanding of physical symptoms.

We are just starting to recognise some specific disease processes that may account for some instances of psychiatric symptoms, such as autoimmune inflammatory disorders, but this is in research stages only, and has not yet translated into any new methods of treatment. For the vast majority of instances of depression and anxiety we really have no idea what the underlying biological process or “disease” is.

Now the keen listener will realise that this is not too dissimilar from our position with physical symptoms. Whilst we understand a lot of disease processes that may produce physical symptoms, because humans experiences such a wide variety of symptoms, the majority of these are not explained by any one particular disease. The take home message from the first few episodes of this podcast is that most of the symptoms we experience are not related to a disease or condition that western medicine fully understands or knows how to treat, and the same is true for anxiety and depression.

We also discussed that even though we may not always understand the root cause of why we feel unwell, on a biological or molecular level, this does not mean that we are powerless to influence our state of health. Because we know about the condition’s humans need to heal, grow and thrive, all we need to do is to provide the right environment and allow nature to take care of the rest. We also considered how sometimes less is more, how the more we interfere, the more tests we have, medications we take, and procedures we undergo; the more we worry about our health, the more unwell we can become. We need to be careful that our treatments are not worse than the disease we are trying to treat.  The same goes for depression and anxiety. We may not fully understand the biochemical processes that produce these symptoms, but we do have an idea of what thought patterns, situations and lifestyles are likely to exacerbate or relive them.

It is likely that the causes of the symptoms of depression and anxiety are very different for different people, and that there are a wide variety of different underlying disease processes that can produce these symptoms. And just like with pain, often they can be produced by things that we do not really consider to be diseases as such, like trapped wind causing abdominal pain.

It is important to understand that this does not make the symptom any less severe or unpleasant, and it does not mean that we are any less entitled to care and compassion, although it may mean that the most effective method of treatment might be different. Trapped wind, despite not normally being considered a disease, can actually cause pretty severe abdominal pain, and conversely some serious diseases can cause very few symptoms at all. I have personally seen several people in A+E with crippling abdominal pain that has completely settled following a good fart.

We also discussed the idea that statistically, for any individual symptom I see, it is more likely that no medical cause will be found. This is because physical symptoms are incredibly common, whilst serious diseases are thankfully relatively rare. Studies have shown that the average person experiences around 5 symptoms every week, and only around 10% of people manage get though a single week with no medical symptoms at all. (1)

When I used to work in A+E my favourite game was betting on the outcome of investigations or blood tests. The standard bet was a Costa Coffee. The safe money is always on a negative test. No heart attack, no appendicitis, no intercranial bleed. I have won a lot of coffee because I know that symptoms are far more common than serious diseases. Of course we still do the test, I may be willing to bet on coffee, but I’m not going to bet on someone’s health.

The same rule applies for anxiety and depression. For the majority of us our symptoms of depression and anxiety are probably not caused by a disease as such, but are the result of the thoughts that we think.

In general, we do not feel sad or anxious for no reason. These emotions and physical sensations in our bodies are the direct result of the thoughts we are thinking, of the sentence we have in our minds at the time. Sometimes the thoughts that are producing the emotion may be at a subconscious level, but if we search for them, we can normally find them. If I feel anxious before an exam it is not the exam itself that is making me anxious, but a thought in my mind about it – I might fail, and that would make me a failure. I might lose the respect of my family, friends or colleagues. I might lose a lot of time and money preparing and paying for a retake. These sentences might not be in the front of my mind as I take my seat trying to suppress my nausea, but they are still the underlying cause of the sensation. If I thought, and really believed, that I was going to Ace the exam then I wouldn’t feel anxious, in fact its more likely I would feel excited at the opportunity to show off my skill.

We all know that if we think a bad thought about ourselves this will produce a bad feeling or emotion. If I think the thought “nobody likes me because I am too short” this will make me feel sad. If we get into a pattern of continuously thinking bad thoughts about ourselves and the world, we will also continually have bad and negative emotions.

Continuous negative emotion is what the psychiatrists refer to as depression. If the cause for our mood disturbance is the thoughts that we are thinking, then the treatment is to change those thoughts. It doesn’t matter how many antidepressants I take, if I continue to think “nobody likes me because I am too short” I will continue to feel sad. That is why when we use other mood-altering drugs they tend to magnify what we are already feeling. It is commonly understood that drinking alcohol can help us to have a good time, but if we are already feeling low it tends to make us sadder. 

If the key to improving our mental health is changing our unhelpful, painful thoughts, the treatment will be mindfulness, psychotherapy, thought work and lifestyle.

We need to be careful that we do not make the situation worse for ourselves, as doctors, as patients, and as a society, by viewing these symptoms as a disease, as something that is fundamentally outside of our control, that needs to be treated by somebody else, with mind altering chemicals. To do so may deprive us of the self-belief and motivation that we need to get better.

Now, I am not saying that there is never a physical or biochemical basis to the symptoms of anxiety and depression, what medically we might refer to as “organic” depression. I am not saying that anxiety and depression is “all in your head”. On the contrary I suspect that biological factors always have a role to play. I am also certain that for some psychiatric symptoms there are clear cut disease processes that are the primary driving force behind them. There are already lots of examples of this known to western medicine. Wilsons disease, for example, can present with psychiatric symptoms, and very common conditions such as Alzheimer’s disease can cause significant mood disturbance and personality change.

There are undoubtedly thousands of other disease process that western medicine simply knows nothing about. The problem, though, is exactly that. We know nothing about them. For today, right now, it can’t really help us to feel better. Maybe in the future we will know more, and we will be able to treat some people with depression with targeted therapies aimed at an underlying autoimmune or metabolic disease, but unfortunately that day is not today. Even as new disease processes are discovered, it is likely they will only benefit a very small subset of people with depressive symptoms, since not everyone will be suffering from the same disease.

All is not lost though. Although western medicine has not yet caught up with the vast complexity of the human mind, or the incredibly complex integration between body and mind, there is still plenty that we can do to promote good mental wellbeing. By creating the optimum environment in our lives for human growth, we can repair and heal and be well. By looking after our physical, mental and spiritual wellbeing we can find balance and with it health. As we already discussed physical and mental health cannot really be separated, and the key to both lies in the thoughts that we think, and the things that we do.

When people come to see me with symptoms of depression, they often want me to tell them if I think they are depressed: In my medical opinion do I think they have depression; are they “clinically” depressed? I don’t think this is a very helpful way to understand depression. Suppose I say “Yes, you are depressed”, what does this mean? What difference does it make? People want to distinguish between “feeling a bit low” and “having depression” but personally I don’t think this is a helpful thing to do. The treatments for “feeling a bit low” and for “having depression” are exactly the same. The diagnosis doesn’t help you in any way.

For me the important question is “are you suffering”? If the answer to this is yes, then we need to do something about it, regardless of if you are suffering because “things have become a bit much” or because you “have depression”. Suffering is not a competition, and we cannot have a monopoly on suffering. We don’t need to meet a certain threshold before we are absolved from blame and responsibility and become deserving of care and sympathy.

If you are feeling low, or are experiencing anxiety, that is interfering with your enjoyment of life, if you are unable to live the life you want to live, then you have a problem. You have a problem that is deserving of love, care and attention. You have a problem that you are not to blame for, but that you are responsible for. You have a problem that you owe it to yourself to do something about. You can call that problem depression and anxiety, or you can call it being overwhelmed, or you can call it the blues. It doesn’t matter what you call it. What is important is that you can cut yourself some slack, that you can recognise the problem without beating yourself up for having it. That you can approach the situation with loving kindness, and with compassion for yourself. You do not need a diagnosis to give you a licence to have this compassion.

It is also important that you don’t allow a diagnosis to take away your responsibility and with it your power. If thinking of your problem as depression is empowering for you, if it helps you to find compassion, and with-it strength to find solutions, then it is a helpful diagnosis. If it causes you to abdicate your responsibility, if the diagnosis is used as a reason to avoid facing your reality, for dealing with your demons, if it causes you to turn not to self-compassion but to self-pity, then it will be a harmful diagnosis.

For the vast majority of us the reason we feel anxious and low is because we are thinking bad thoughts about ourselves, about our situation, about other people and about the world. It is not because we are suffering from a medical disease that needs treating by doctors. The treatment is to stop thinking bad thoughts, and the way to do that is through mindfulness, psychotherapy, thought work and lifestyle. Only we have the power to change the way we think, how we feel and what we do, and so if we want to get better, we have to accept responsibility for the way we think, the way we feel and what we do. This is the case irrespective of whether or not a doctor has labelled you with a diagnosis of depression, anxiety, ADHD or personality disorder.

I’m going to leave it there for today, but I am aware that there is an elephant in the room.

What about antidepressants? What about Sertraline and Venlafaxine, Serotonin and noradrenalin? I have not forgotten about these, and of course they do have a role to play. But I think these medications are often misunderstood, by both doctors and patients, and so I am going to give them a whole episode to themselves. We will call it Part 2. So hopefully you will join me here next time.

In the meantime, I have no set homework for you this week, but since episode 9’s homework was to “go have psychotherapy” I suspect that you have plenty to be getting on with for now. I hope that you are making progress!