TREATMENT OF DEPRESSION: THE MODERN WAY

DR. M.T. HASLAM 

I had known Jonquil - we will call her Jonquil as that is not her name - since she was 15 and, in those days, a patient of mine in an adult ward - nearly 25 years ago.

One of the rewarding parts of psychiatry is the way one develops friendships from client relationships and such people may keep in touch over the years, long after my professional contact has ceased.

Jonquil at 16 was a self-mutilator.  The cuts on her forearms, cigarette burns and the loss of a small part of her left ear as a consequence of hr blouse catching alight bore testimony to the problems of her late teenage years.  She had phases of deep depression - phases of rebellious behaviour - but then one would if holed up in a psychiatric unit as a teenager; and a period in her twenties when she heard a voice which appeared to come from inside her head and was directive.

But, over 25 years, she had no deterioration in her personality, no loss of drive and no development of any persistent delusional systems and, indeed, as she matured, she became appropriately stable.

However, she still had episodes of depression and, when she did, the voice experience occasionally recurred: perhaps once in three of four years.

There were no environmental precipitants of her first illness nor of her recurrences.  She knew that.  I knew that.  Indeed, the world apart from "therapists" of various persuasions and brief trainings knew that.

Jonquil had insight.  She had discovered that when she felt intolerably tense in her first illness that self-mutilation provided a respite and, despite the local pain, produced a feeling of relief.  We all know how endorphins work and Jonquil's self-provided "acupuncture" worked well - apart from the scars.

Anyway, she had grown out of that.

She also knew her family history.  Three out of eight first-degree relatives over three generations had had not dissimilar illnesses.

She also called a spade a spade.

So much for the background.  She had acquired various labels over the years - 'Adolescent personality disorder' - probably - Psychopath - no way!  She had none of the long-term traits over the years that justify that stigmatising label.

Schizophrenia on the basis of the voices - not by my definition.  Schneider would have wanted more first rank symptoms than that.  She was now 39, had been engaged for a couple of years and, although not in work (long term unemployed female of nearly 40 with no particular skills - what work?  She had as much chance as a pre-op transsexual trying to following the real life test insisted upon by Charing Cross) was filling her life constructively.  She had worked for two years as a domestic at a private psychiatric nursing home but had been 'terminated' after being off for six weeks with a relapse - that was called the caring society.  So - to the diagnosis - 'Atypical cyclical affective disorder'.  Good one.  What does it mean?  God knows, but she's not on the phone.

She had had the gamut of treatments.  Antidepressants - the usual:  neuroleptics.  She got a reaction to haloperidol with Parkinsonism symptoms even on small dosage - and a bit yellow with largactil - that wonder drug of the fifties that should be in every psychiatric museum - but nowhere else maybe - that one University senior lecturer was still in the 1980's saying to the students was the drug of choice in schizophrenia - but anyway she didn't have schizophrenia - a burst of E.C.T. in her early twenties, and two drugs that had, at the time, been quite helpful, namely a small dose of sulpiride and viloxazine in the days when you could still get it.

I had had a coffee with her some three weeks before her last relapse.  She had been her normal self - no problems, no worries, happy.  Then, in March, her mood suddenly swung down and she went into a patch of morbid thoughts, tension, sleep disturbance and irritability.  Her GP referred her to the local unit.  Her consultant was a lady on with whom she did not get!   Dr. X shouted at her and got annoyed if she did not choose to take her advice.  Dr. X declined to use the medication that Jonquil knew had worked for her in the past - obviously she had not read the old notes, and on the last referral but one had put her on haloperidol (why?) with the anticipated consequences.  So Jonquil had little faith.  My own polite letter to the unit had been ignored as interference - not that it mattered as Dr. X had not seen her anyway.

On this occasion she was - somewhat reluctantly admitted.  She was seen by a nurse therapist (no doubt part of the 'process') and asked to fill in a questionnaire.  I remember the days when patients with depression were allowed to be at peace during recovery.  If they went to O.T. they did some non-taxing activity such as weaving a basket and they went for walks in the beautiful hospital grounds; very old-fashioned!  Now they must attempt to tax their brains with quiz games, interact with 'therapists' and of course there are no hospital grounds any more to walk in.

Jonquil knew hospitals well.  She had filled in forms many times.  They did not aid her recovery.  Time was the great healer - and perhaps a bit of medication that didn't give her side effects.

She made an attempt at the questionnaire, however, but left out the bits that she felt were irrelevant.

The therapist - was she a nurse - a social worker - a psychologist - or even another patient?  How did one know?  They all wore scruffy clothes though the staff often had a name badge - was not pleased.  "You haven't filled in question 4".

"Which one is that?".  "The one about possible precipitants - and you've done nothing about environmental problems".

"There aren't any."

"But you have to put something down or we can't score the questionnaire."

"Bugger the questionnaire!"

The therapist left.

The junior doctor accused her of being unhelpful.  She was written up for melleril and Tryptizol.

"But that makes my mouth very dry and I feel terrible on it.  I've had it before, if you look in the old notes.  It didn't suit me.  Why can't I have the stuff that worked before?"

"Dr. X doesn't use that particular medication.  Anyhow she prefers to make her own mind up about what treatment is best and not rely on old notes."

Jonquil acquiesced.  It was easier.  After a day or two the Parkinsonism symptoms recurred.  Dr. X came to see her.  Jonquil had a burst of irritability and said "I told you so!"  Dr. X shouted at her and went away.

The staff wanted Jonquil to be participatory - join a group discussion about depression and bare her soul.

Jonquil told them where to put it and was discharged the following wee on no medication and a note to the GP about her uncooperative behaviour.

The key nurse - whom she had only seen once as she'd gone on a course - arranged follow up at the day unit.  Jonquil turned up for this and was asked to fill in a form about her feelings and why she thought she was depressed.  I doubt they kept it.

I met her again some three months later.  She had staggered on for a couple of months with the help of her fiancé, and had taken a turn for the better and was now back to her old self.

We had a drink together.  "You know the consultant only saw me twice while I was in.  And shouted at me both times.  I expect I was bloody lucky she only came twice.  Nobody really listened to me at all!"