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It’s time to change the way we make sense of human misery



What follows is a doctor-patient interaction that I hope will become more commonplace across psychiatric outpatient clinics:


[After a 15-minute initial interview]


Psychiatrist: Mr Smith, it is clear you are suffering from a depressive illness.


Mr Smith: Oh, OK. It’s reassuring to hear that you know what’s wrong with me.


Psychiatrist:  Yes, a clear-cut case of major depression, an increasingly common mental disorder.


Mr Smith: It’s good that you’ve pinpointed the cause of all my distress. But can I ask, how can you be sure I have this illness?


Psychiatrist: You’ve got all the classic symptoms: low mood, suicidal thoughts, loss of appetite, not enjoying life – there is no doubt. Also, you told me about how your father suffered prolonged periods of low mood; these things run in families you know.


Mr Smith: So I’ve inherited this illness from my father?


Psychiatrist: Yes, in all likelihood.


Mr Smith: So a gene has been identified for this thing you call depressive illness?


Psychiatrist: Ah, no – it seems like many genes make a contribution. We’re as yet unsure as to which ones, but there’s lots of research underway to find out.  


Mr Smith: But it is primarily a biological problem, an illness like any other?


Psychiatrist: Yes


Mr Smith: I’m so relieved you’ve identified the source of my difficulties. I’m embarrassed to admit that I was thinking my recent despair might have had something to do with the death of my parents earlier this year, my wife leaving me for my best friend, losing my job last month, and the assault I suffered during karaoke night at my local pub.  How stupid of me! I’m pleased I consulted a medical expert who can diagnose the true source of my problem so quickly.


Psychiatrist: Don’t mention it – it’s my job.


Mr Smith: But, with respect doctor, you haven’t carried out any blood tests or brain scans, so how can you be sure I’ve got this illness?


Psychiatrist: We don’t need those tests to identify a depressive illness. We can diagnose from the symptoms you describe.


Mr Smith: So how is it decided that these particular symptoms indicate that I have got this biological illness? I once read some mumbo-jumbo that diagnoses such as these were dreamed up by some blokes sat around a committee-room table in the USA, by a show of hands. But of course that isn’t the case, is it doc?


Psychiatrist: Eh, well, not really … these people are medical experts, consultant psychiatrists.


Mr Smith: Ah, that’s good to hear. So these experts know there is some underlying biological abnormality purely from the changes in my mood and behaviour?


Psychiatrist: Yes, that’s it. So shall we move on to discuss … …


Mr Smith: Sorry to interrupt, doc. But what precisely is this biological abnormality that’s causing all my distress?


Psychiatrist: We’re not entirely clear about that; probably something to do with lack of a chemical messenger in the brain.


Mr Smith: Are you referring to serotonin?


Psychiatrist: Yes that’s it. So let’s move on to look at the treatment options that … …


Mr Smith: I thought these chemical imbalance explanations of mental distress had been shown to be a load of bollocks.


Psychiatrist: Well, eh … there has been some debate … … and we’re not entirely sure about the exact biochemical mechanism underpinning this mental disorder. But the good news is it doesn’t really matter as we can give you antidepressant medication that will make you feel better.


Mr Smith: Four pints of cask ale each evening makes me feel better, but I’ve never regarded that as a long-term solution.


Psychiatrist: Alcohol is most definitely not the answer, young man. It will lead to further physical and psychological problems, and you risk becoming dangerously dependent on it.


Mr Smith: Just to be clear in my mind, doc, these antidepressants don’t have these disadvantages?


Psychiatrist: No… … not really. There could be a few minor side effects and, unlike alcohol, they are safe and most certainly not addictive. So take this prescription to the pharmacy and … …


Mr Smith: Sorry for interrupting again doc, but I think I read somewhere that these depression pills often cause some nasty side effects, like crushing headaches, nausea, insomnia, weight gain, diabetes and – God forbid – erectile failures and being unable to pee. Perhaps this is total nonsense?


Psychiatrist: Listen young man, there has never been a medication invented that doesn’t sometimes cause side effects. In regards to antidepressants, these side effects are typically minor and last no more than a couple of weeks. The antidepressant effect takes a few weeks to kick in, so you mustn’t stop them just because of a few minor teething problems.


Mr Smith: So you’re recommending I take these tablets for a long time? Weeks and months rather than days?


Psychiatrist: Yes, that is correct.


Mr Smith: But aren’t they addictive? 


Psychiatrist: No, no, no, no – withdrawal is rarely a problem with antidepressants. These psychiatric medications are not like alcohol or street drugs.


Mr Smith: So that article I read in the Guardian was a pack of lies?


Psychiatrist: What article?


Mr Smith: The one that stated that a comprehensive review of the research had found that over half of longer-term users of antidepressants suffered significant withdrawal symptoms, many of these being severe and debilitating, and lasting for many months?


Psychiatrist: Look young man, all I can give you is my expert, impartial advice; it is up to you whether you … …


Mr Smith: Who are Eli Lilly and Pfizer?


Psychiatrist: What?


Mr Smith: I’ve just read them on your coffee mug and wall calendar?


Psychiatrist: Get out of here before I call security.





Photo courtesy of Stuart Miles at 

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