Conclusion

In the last decade I have experienced a relapse of my depression every couple of years or so. I have now taken one antidepressant or another continuously for more than 20 years. I have experienced some side effects, but I can usually tolerate them. My periods of low mood, which have from time to time been more severe, necessitating a change in my treatment, have almost always been triggered by life events related to my work. My skin is still too thin and I am easily wounded, and I still live my life in a state of perpetual fear of being discovered to be a fraud. I am frequently anxious. Day to day life can still be a struggle. Yet, despite experiencing depression, I have achieved a great deal in my work and been very happy in my second marriage; I think both of these owe something to my extended therapies and medication, and each of these methods of treatment has played an important role.

I am quite sure that depression isn't just the list of symptoms found in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association or in the International of Classification of Diseases. These are approximations, constructs and guesses as to what 'depression' might be. They are useful for helping us in research and clinical work, but should not be seen as essential truths in their own right. Unfortunately, they are treated as such every day, all over the world. I suspect there is not a single depression, as DSM would have us believe, but many different 'depressions', with some features in common and others which are very different.

There are people everywhere who suffer, who feel cut off from the world, who feel life isn't worth living and who kill themselves. They share a lot of experiences – undoubtedly including the symptoms of depression that psychiatrists learn by rote and always ask about – but each person has a different story to tell about their misery, and there are many different reasons why they have become depressed. Their life problems, as I have tried to show in this book, are not simple but complex; they are intertwined with the other realities of the human condition: our vulnerability, fears, losses, wounds, the need to be loved, the pain of loneliness, the difficulty in trusting others, the problems in our past and unresolved grief. It's impossible to really help a person who is depressed without acknowledging and addressing these experiences. This is why medication on its own is never the answer.

I believe, too, that biology plays an important part in how and why we experience depression. I have learned over the last few years about the biological changes that can be seen in the brain in some, but not all, people who are depressed. We inherit the genes that make us vulnerable from our parents. Depression is, for many, an extraordinarily physical experience. The terrible feeling of torpor that psychiatrists call 'psychomotor retardation' is more than simply a psychic phenomenon. Something – although we still do not entirely understand what – happens within our brain functioning and results in the 'epiphenomena' that are the symptoms of depression: low mood, inability to enjoy life, loss of energy, inability to think clearly and feelings of hopelessness. These can be reversed with medication, at least to some degree. But in people who are chronically and severely depressed, there are changes which can be seen in the structure of the brain. When a person has experienced one episode of severe depression triggered by stressful life events, there seems to be some kind of 'kindling' effect in the brain which makes further episodes more likely to occur. Believing this does not mean that I am in any way a biological reductionist, one who only views the causes of illness in simple biological terms – far from it. I don't have any personal sense of whether my 'inflamed' brain (inflammatory theories are the latest in many different biological theories of depression) has structurally changed in some way or if my neurotransmitters – the chemicals which help to relay electrical impulses – are up to full strength (although it can feel like they aren't when I'm not firing on all cylinders).

Severe depression is a singularly awful experience. It saps the life out of the sufferer. It makes each day seem like a lifetime. Indeed, I think that those who seek to explain depression as no more than 'understandable distress' in response to life events are just as guilty of a kind of reductionism as the neuroscientists who pore over the MRI (Magnetic Resonance Imaging) scans and the psychologists who seek to break everything down into instances of 'negative thinking', which can sometimes make the sufferer feel as though it is their own fault for not thinking more 'positively'. Depression is related to all of these factors, and at the same time it is none of them. For each person, the parts that the different dimensions of biology, psychology, life events and difficulties (such as grief, physical ill health and social isolation) play in both precipitating depression and maintaining it will be important to a differing degree.

Depression is a profoundly personal illness. It burrows into the soul and damages our sense of who we are and our reason for living, in the same way a worm makes its way to the core of a ripening apple. We all have to find our own ways of managing the damage it causes, but I know from my own experience that it can be done.

Although I am not a religious person, I do know that some people find faith a great support in overcoming depression. Perhaps priests really are the only people who can help us to nourish our souls, but personally I doubt that. I've spent most of my life helping people to patch up their souls in order to keep going and accepting help from others in repairing my own.

Despite what some may say, asking for and receiving help is really nothing to be ashamed of. It demonstrates that you are doing something about how you feel rather than trying to hide it, which only brings more problems. Unfortunately, many societies, including our own, are not yet ready for such a level of honesty, but I know my depression is not something I should be – or am – ashamed of.

I have learned how important it is to be able to really connect with another person in order to be able to understand and overcome the problems related, in one way or another, to my depressed mood. To be able to have a frank, open and meaningful conversation with another person is, as Bob Hobson (a psychotherapist who supervised my therapy in my early career) said in his book Forms of Feeling, crucial in enabling us to explore, learn and modify how we deal with our difficulties, especially those concerned with our significant relationships. I've learned this not just from my work, but from my very own personal journey through depression.

I am beginning to learn the need to nourish my own soul in order to prevent relapse, rather than simply mend it when it is broken. I have survived. I have even been successful in my chosen career. Perhaps my father would have been proud of me, although I suspect he would have never been able to tell me so face-to-face.

As I write this, I am once again in Scotland, sitting at my desk, looking out from my window over moorland on the mainland of Orkney, and planning for the future. The time has finally come to relinquish my work and learn how to take better care of my own 'self', body and mind, and those who are important to me. This is the next challenge, and it is something that we can all do to help ourselves overcome depression.