Chapter 11 - Taking the Tablets

When he first came to see me in the clinic, Alan had lost all hope to the point of feeling that his life was not worth living. He was a middle-aged heavy-goods driver, who travelled the country most of the week. He appeared slightly dishevelled, as though he wasn't taking particularly good care of himself. His fingernails were ragged and dirty, and he was unshaven.

'It says in the letter from your doctor that he has prescribed some fluoxetine…' I began, as I scanned the referral. Fluoxetine was an antidepressant. His GP didn't generally send people to me, unless he had already tried to treat them or was really worried. He was very skilled at helping most people who were depressed.

'I haven't taken them, though. I'll be honest. I mean, I told the doctor flat-out that I wouldn't. He's been trying to get me to for weeks.' He looked up at me, a little shamefaced perhaps, waiting for what I would say next.

'And now you are here… How does it feel?'

'A bit scary, I guess. But I told him I'd come.' He shrugged as though there really was little else to say.

A little while later, after Alan had told me his story, I asked him, 'So can you tell me why you didn't want to take the medication? What are you worried about?'

'Well, I'm not worried… as such. It's just that I know what the problems are: I hate my job, my wife hates me, my kids hate me and I don't see how taking a tablet every day can change all that!'

'And how are you feeling at the moment, today?'

'To be honest, Doc, I can't sleep, I can't eat, I can't think. I wouldn't care if I was run over by a bus tomorrow. Do you know what I mean? And I don't think anyone would miss me. There's just no point to life any more.'

'Have you considered taking any steps to end your life? Sometimes people do when they feel as bad as you do at the moment.'

'Well, I've thought of driving the load off a bridge. I wouldn't be telling the truth if I said it hadn't crossed my mind…'

'Well,' he looked at the wall of the office and then at me, and I could see tears welling up in his eyes. He blinked and one trickled down his cheek. He wiped it away with his fist. 'Pretty often to be honest.'

'And what has stopped you from doing it?'

'My kids,' he admitted, before bursting into tears and burying his face in his hands. 'I couldn't do it to my kids.'

When I once again reached a moment when there seemed little point to living my own life, it was still strangely unexpected, despite what had happened in the past. If I had recognised, in the midst of my constant mental replaying of events at the hospital, the echoes of the awful winter in Edinburgh, when the future could no longer be glimpsed as a shimmering promise on the horizon, I might have done something sooner. Instead I ignored the warning signs: the early-morning wakening, the sapping of energy from my limbs, the increasing irritability and anger. And then there had been a series of losses, each of which undermined the tenuous hold I still had on my sanity.

Sam was a GP I had known for several years, and he worked in a village near the mental hospital in which I was now working. He had been a source of much needed support during the previous year. The last time I saw him, we shared a glass of wine in his kitchen. He told me about the eccentric behaviour of my predecessor at the hospital, whose approach to managing one of Sam's patients with an alcohol problem had been to empty the entire contents of the patient's cocktail cabinet into the boot of his car and drive away with it.

Eventually, this consultant, who had on occasions been reportedly too intoxicated to take the ward round, accepted retirement, with a generous pay-off. But not before he tried to intimidate me with a letter from his solicitor. I realised an indiscreet comment I had made about previous standards of care must have been conveyed back to him, possibly by one of his regular drinking companions.

One Saturday afternoon, as John and I were driving home, we heard the shocking news on the Radio 4 bulletin at 3 o'clock. Sam's climbing group was, I learned later, painfully ill-kitted-out for the unpredictable conditions of Scotland in spring and was caught in a blizzard with only one pair of crampons between the three of them. All of them, including my dear friend, were found dead.

The fact that he had been my therapist was a secret known only to one or two people. And E was in disgrace; I had discovered a couple of years after he disappeared from my life how he had been suspended from his post and then dismissed for reasons unknown. He had become a persona non grata in the circles in which he had once been local aristocracy as a senior therapist. I knew very little about what happened to him. Now I would never see him again.

One Sunday evening, as I contemplated the long early Monday morning drive back to work in the winter fog, my mind seemed at last to disintegrate into small sharp-edged monochrome pieces. I was unable to think with any clarity. I sank down into the sofa in front of the fire and wept. John found me there, in a room lit only by the ghostly glow of the coals in the stove, watching the flames and listening to the fire crackle as the air was sucked in through it, yet strangely unable to feel any warmth. I was just cold and lifeless. He sat down next to me and cradled me in his arms, stroking my head gently as I sobbed and shook. I was forced to admit at last that there was something seriously wrong with me.

What I know now, but was only beginning to learn then, is that a consultation with your general practitioner is like a dance. Both of you in turn 'hold the floor', as social psychologists call it, and enter into a negotiation which has a clear beginning, middle and end. If you want your doctor to know more about you, you have to give him the right kind of cues: the words that hint at just how crap you are feeling. The doctor then has to pick up these cues. He might not necessarily feel obliged to explore your problem unless he is interested enough, but you may not want him to anyway. You may want to get out of there as fast as possible and just resent any attempts on his part to 'analyse' you. I knew that GPs varied a great deal in their interest and expertise in helping people with depression. Some were comfortable in talking about it, whereas others asked the right questions but didn't necessarily understand what it really felt like. Then there were a small number with whom you would feel very cautious in talking about feelings at all.

I knew exactly what I wanted. I had tried talking therapy and it had worked for a while. My life had been turned upside-down by the work I had done in my sessions with E and the decisions that it enabled me to make. I still believed those changes were only for the best. For a few years I had allowed myself to hope that I would never feel so unbearably anxious and fearful again, but then the bleak, hollow feeling returned. This time I also felt exhausted, weak and dead inside.

I liked my doctor. He was a giant of a man about the same age as me, with the look of someone who, like Sam, spent his spare time climbing mountains and vaulting streams. He clambered up real peaks, wet rock faces and crags with treacherous slopes – there were photographs of them all around the walls of his consulting room. He probably took risks but, I suspected, always with due regard to safety. There was something immensely reassuring about him.

However, I wasn't sure whether he really got what it was all about for me. What I scaled were the obstacles in my mind. I felt then, and still do now, that I was living on the edge of the abyss and sometimes, I suspected, I wilfully threw away the rope. I had begun to see that others thought I did this. I didn't think my doctor quite understood, but I watched him trying hard to do so.

'How have you been sleeping?' he asked.

'Not good. I wake up early in the morning, and I lie there thinking about everything and getting anxious.'

'What do you think about?'

'Work, all the problems I've told you about before.'

'What do you do then?'

'I get up and make a cup of tea.'

'What's your energy level like?'

'Terrible. I just want to sleep.' I helped him out: 'But I can't sleep and I've lost interest in most things. I think I'm losing weight too.'

He paused for a moment and considered what he had written. Then he looked up at me. 'So do you want to try an antidepressant?'

'Yes, I think I do.'

He knew he didn't have to tell me what they were. I knew only too well. I was a psychiatrist after all – I gave them to my patients, too. I was also desperate enough to try anything in order to feel better.

There were things I did not tell him: how I cried myself to sleep on a pillow, damp with sweat and tears; how I believed I was hopeless at my work and could never make a success of anything; how I felt isolated from the world and cut off from everyone around me. I did not tell him about the recurring dream in which there was a task I had to do – an examination to pass, a piece of work I had to finish – which required me to depend on others: colleagues at the hospital usually, but sometimes my mother appeared, or my father, and I found myself back in the home of my childhood, in my bedroom. Whoever I had to confront did not want to do what I wanted them to do and so we began to argue, because of my certainty that they must do it. I stated my case in clear and precise English, or at least this was what John would tell me in the morning ('You've been talking in your sleep in paragraphs again'), and I spoke the words aloud to the waking world, sometimes bringing myself into consciousness in the process. This dream world seemed all the more real to me because of the power of inchoate emotion with which it was imbued. I was thwarted at each turn, as though I were trying to move through glue – viscous, sticky, sealing me off from the world – and the final steps I needed to complete in order to achieve my goal were getting harder and further away.

I also did not tell my doctor about the terrible weight pressing down on my chest, which became lighter when I cried or talked to John, but only for a while. When it returned, it was as if an invisible demon had loaded ten more pounds on each side of a bar that I was unable to push off my chest. Maybe this is where the expression 'getting it off your chest' comes from, only I couldn't. The talking didn't work any more.

I started to recover after two or three weeks on the tablets, that first time I took them, and from then on I stayed on and off medication for about three years, while I coped with more examinations, and changes in my job and my home. As I had experienced the effectiveness of taking the pills, I was well aware that the cause for the return of my depression this time was not just linked to everything else that had happened over the preceding year. Three months before the severity of my decline had become apparent, I had stopped taking antidepressants once again, despite the serious difficulties that I was facing at work. And as a result the depression was back again, with all the same symptoms, but with greater intensity than ever. The weight on my chest was too heavy and I no longer had the strength to shift it at all. My body felt as though lead had seeped into my blood vessels and bones, slowing down my whole being.

This time, I didn't go to see my GP immediately, but instead I called a colleague and friend, Susan, who was one of the few people I trusted to give me an honest and forthright opinion of my mental state. She asked me to come and see her that same afternoon, at Prestwich Hospital just north of Manchester. I didn't contact her because of the job she did then, but because I knew she had trained as a psychotherapist. Even if I suspected, though with some ambivalence, that I needed first and foremost more medication, it was important for me to talk to someone who would be able to appreciate my story as well as my symptoms.

We met in a small room off the main hallway of the old administrative building at Prestwich Hospital, and its similarity to the other mental hospital where I had been working caused me at first to hold my breath. Inside, the place had the same aura of neglect and drabness: dark woodwork, worn linoleum and unpolished brass in a room only barely lit by windows stained black by decades of Manchester soot and rain. But despite the physical similarity between the institutions, there was a different atmosphere here: a sense that this might possibly be a place of real asylum for me, a feeling that I was near a potential source of help. A person I believed I could trust greeted me, smiled and took me into a room just off the main corridor, while John waited for me outside.

Susan set about taking my history, with the sensitivity and care I had hoped for. As I feared, however, it was not long into our conversation before she approached the death question.

'I have to ask this,' Susan looked directly at me with her clear and calm grey-blue eyes, 'have there been times when you have felt so bad that you have thought life isn't worth living?'

'Yes,' I replied. There was a sense of relief to be able to talk about it but it wasn't easy to find the words to describe such a painful feeling, and I could not stop sobbing as I replied, 'Sometimes when I'm on the motorway… driving… I just can't get the thought out of my head that I could simply put the handbrake on when I am speeding. I know it would spin the car and turn it over, and I don't think I really want to do it… but I can't… I can't get it out of my head. I can't stop thinking it.'

'So you know what you are describing,' she said, looking up at me again as she stopped writing for a moment. 'Do you think these might sometimes be obsessional thoughts?'

I had talked about my brother's illness, and the delay in beginning to grieve for my father. The past I had tried so hard to leave behind was catching up with me once again. I told her about the problems I had been having at work. 'So do you think I'm paranoid?'

'I don't know,' she replied. Then, after asking me a lot more questions about the feelings and thoughts I had been having about the hospital, she said, 'OK, possibly you have been a bit paranoid in your thinking, but this is understandable given your mood at the moment. It doesn't mean there haven't been some very unpleasant things going on, but do you think you might have just got them a bit out of proportion?'

I nodded. I knew what she meant. I might be paranoid, but it didn't mean the buggers weren't really out to get me.

'I think,' Susan paused for a moment, 'that you are really very ill, and I'm so pleased you got in touch and came to see me. I know how difficult it must have been for you.'

'Thanks for seeing me so quickly.'

She looked directly at me. 'I can tell you what I think. I think you have a severe depressive illness. But what do you think?'

Susan's words did not come as a complete surprise. Yet, despite taking antidepressants intermittently, and considering all my knowledge and training, it was still difficult to accept this diagnosis.

One of the problems for me was the growing belief among many members of my profession that depression was primarily caused by biological factors: changes in the level of chemicals or 'neurotransmitters' in the brain. This message was reinforced by the drug companies that were energetically promoting the latest type of antidepressants, 'selective serotonin reuptake inhibitors' (SSRIs), such as Prozac. As Tim Lott says in his memoir, The Scent of Dried Roses, it is really hard to believe that the complexities of human thought can be explained by a simple chemical imbalance. I did not believe then, and still do not think, that the nature and essence of mental illness – the most subjective and personal of human afflictions – can be distilled down to something quite so simple. Nor did I think that treatment was quite as straightforward as just the replacement of a substance depleted from the brain. I was trained to consider biological, social and psychological determinants of mental illness, and had always leaned towards the latter two in my approach to therapy, although I did prescribe medication too. Yet, at the same time, I could appreciate the positive aspects of the biological explanation for depression; it did legitimise my absence from the hospital – I was unwell and needed help – and it did begin to absolve me of a sense of responsibility for my own condition, although guilt is difficult to banish from your world when you are depressed.

What is even more difficult to understand sometimes is the dilemma that my patient Alan posed. How can tablets help when it's perfectly clear that the cause of the problem lies in external events? It isn't always easy to answer this question. Life events trigger depression, but then it sometimes seems to take on a life of its own. This follows a particular trajectory, which may be brief, especially if a positive life event – known by researchers as a 'fresh start event' – happens to boost recovery. Alternatively, it may be much more prolonged, particularly if the problems that triggered it are not resolved. 'I can see why you might wonder how taking a tablet each day would solve your problems,' I began, looking at Alan.

He nodded. 'Absolutely.'

'And you're right; the tablets won't make your problems disappear, of course. But what they will do, after a couple of weeks, is begin to boost your energy and help you to sleep a bit better. They will help you to think more clearly again and to feel more up to beginning to sort out some of these problems.'

He looked at me quizzically. I had a strong feeling that pushing him was not going to be the right thing to do, even though I was convinced he would benefit from medication. I was seriously worried about his safety.

'I still don't think it's what I want to do at the moment,' Alan declared, looking away.

It was very important that he didn't feel I was determined to make him take the tablets, and I was worried that we would lose the connection we had started to make. So I said, 'Well you have a choice. It's up to you. We could look at the different options, and then you can tell me what you want to do.'

'So I don't have to…'

'As I said, it's up to you. I cannot force you to take them. I wouldn't want to. I can tell you what I think would help, and I think this medication would really help you feel better. You wouldn't have to be on it for a very long time.'

'I wouldn't?' He sounded a little happier with this suggestion.

'But let's just consider all the options first…'

I had succeeded in engaging Alan in a conversation by giving him a choice. He decided to give the tablets a try and began the slow but eventually successful process of recovery, which also included a period of problem-solving therapy to help him tackle difficult decisions about his life.

I pondered the question. I couldn't stand the side effects: the dry mouth and weight gain. When I got out of bed in the morning, I would regularly feel faint due to a drop in blood pressure when I stood up; that was a problem because my bed was at the top of a steep flight of stairs and there was a danger I would fall down them just after rising. The side effects explained, at least partially, my keenness to stay off the tablets.

However, I considered what I knew about them: they had worked for me in the past and my personality had not been changed in any way by taking them. Some people have withdrawal symptoms when they stop taking antidepressants (as I would later experience myself), but they are not addictive in the sense of craving them or having to take an everincreasing dose. I had seen them work for my own patients, particularly those with more severe depression.

I also suspected that she didn't want to give me something which was as lethal in overdosage as I knew dothiepin (now called dosulepin) to be, but she didn't say it. We agreed that I would try the antidepressant paroxetine, but it wasn't the only treatment she advised. Susan was also quite sure, although I had doubts, that I should embark on another period of formal psychotherapy, but in the state I was in, unable to string my thoughts together coherently, there was no hurry. I could wait until a suitable slot arose with the consultant to whom she decided to refer me.

I was nervous about taking new medication, and over the first few days I felt quite nauseous, especially in the morning. I learned to take the tablet with food, which helped me to tolerate it. I also noticed I was getting even more headaches than usual. Apart from giving me side effects, which gradually disappeared, 20 milligrams of paroxetine did not seem to do very much at all. I felt less agitated, but the morbid bleakness did not leave me. I began to wonder if I would ever feel any better, as I still found it difficult to get out of bed before the late morning and – most distressing of all for a person who had always surrounded herself with books – I felt unable to even open one of them, never mind concentrate for long periods of time in order to read. An increase to 40 milligrams didn't make much difference and in retrospect, given what I know now about the comparative efficacy of the SSRIs in more severe depression, this isn't surprising. So, after three months or so of treatment, I started on lithium. It is well known as a treatment for bipolar disorder but, in about half of the people who are not responding to an antidepressant, can also be an additional therapy for depression, as it improves mood fairly rapidly. The problem is that – amongst other more unpleasant things such as kidney disease – it requires regular blood tests and can, as I would discover, cause underactivity of the thyroid gland.

One morning, a couple of weeks after starting the lithium, something happened. I turned over to bury my face in the pillow, which was damp from another night of dreaming, chasing after a resolution to a problem that I could never quite define. I realised that the bed was empty and cold beside me. John was up. What time was it? How long had I slept? I checked for the awful weight on my chest, as it usually caught me unawares in the moment between waking and full consciousness. But this time it didn't. I opened my eyes and looked around: a hint of sunshine through the curtains, the scent of grass wafting in the breeze and the sound of birds singing. When had the birds returned? I hadn't noticed them for a long time.

Something had changed; it was a subtle alteration. Looking back, this was when I began to recover. It was a lightening of my heart, a new ability to notice the world around me again. Could these improvements really be connected to the tablets I had been swallowing every night? I found it hard to believe. Although I knew that tablets could change your perception of the world, I didn't want to believe that the solution to my problems could be so simple – and yet it was true. The terrible weight seemed considerably lighter and, while I could still sense its presence in the wings of my mind, something else was preventing it from taking centre stage: the sound of the birds, the smell of the grass and the brightness of the daylight. The world was singing to me. Life had returned.

The tablets worked for me then and they have continued to work for me on most occasions whenever the terrible burden returns. Without them I don't think I would have survived to wonder again at the sharp, fresh beauty of a spring morning. I know they do not work for everyone, but even the sceptics agree that they do seem useful to some degree when your mood is very low.

I remembered a patient I had seen many years ago in my first year as a psychiatrist telling me how when she was elated, she could actually hear the grass growing in the lawn. I knew then just what she had meant. Ever since my childhood, I had always been hypersensitive to the moods of others: able to pick up and then worry about the significance of minute changes in their words and behaviour. This is the downside of sensitive awareness. But as I began to recover, I recognised other moments when I started to feel totally at one with the world again and back in tune with what seemed to me like the rhythm of nature itself; oceanic moments I would not denigrate with a pathological label.

At those times I wondered whether the weight really had been as heavy as I had thought. Maybe it had not so much melted away as never been there in the first place? Perhaps I had been exaggerating, pretending, trying to escape my responsibilities at work, in life? Wasn't this what everyone else was thinking? It is hard to remember how heavy the burden of depression can feel when all you want is to forget about it.

But I realised once more, just as I had as a medical student, that I found it all too easy to understand how other people, clambering up their own personal mountains of the mind, managed to find themselves at the bottom of a crevasse with no obvious way back up. This time I had found someone who was willing to throw me a rope.