Doctors should get down from the pedestal
Terry Lynch says it's about time doctors stopped prescribing the pills in favour of listening to the real distress of their patients
In my early years as a doctor, I thought I was a good listener, and up to a point I was. As my eyes began to open I increasingly realised that, like my medical colleagues, I had been trained to re-interpret people's stories, to decide which parts of the story were significant and which were not. I didn't realise it at the time, but as a doctor I was in a very powerful position; my interpretation of people's stories decided how these people's problems were dealt with. Hence my ever-growing alarm during those years of questioning, as I increasingly became aware of how grossly inadequate my medical training had been in the area of mental health problems.
For example, it began to dawn on me that virtually every person I encountered with mental health problems had very low self-esteem and self-confidence. As I increasingly removed the blinkers of my medical training, it seemed that such issues were of central relevance and importance to the problems being experienced. I began to see that people experiencing mental health problems frequently tended to be unhappy, lonely, overwhelmed, struggling to deal with life and its challenges, hurt, unassertive, tended not to express themselves; felt very unsafe, or believed themselves to be powerless to improve their life.
I increasingly questioned how I and other doctors could emerge from medical training with such power and influence, yet have so little understanding regarding key elements of the mental health problems we presumed to have expertise in.
I realised that if I really wanted to be effective in my work with people experiencing mental health problems, first I had to greatly enhance my understanding of mental health problems. To this end, I did an MA in psychotherapy at the University of Limerick, which I completed in 2002. However, the main source of my re-education came from my clients. As a consequence of this re-education process, what I was taught in medical school now comprises only a small minority of what I bring to my work and how I understand people's experiences of mental health problems.
The name Depression Dialogues is interesting. In modern, westernised countries such as Ireland, there is little real dialogue around depression, or indeed about mental health problems in general. When depression is discussed, the focus tends to on viewing depression as an illness. Society's appointed experts comment on the impact of depression both on the individual and on society, and offer advice on how it should be treated.
But in our society there is little real dialogue about what depression really is — about the actual experience of depression. People who are experiencing mental health problems such as depression often feel marginalised or excluded, because there is such reluctance to discuss mental health problems openly. This came up recently with a young man who attends me. Over the course of 18 months he had undergone the most important journey of his life — the journey from ever-present terror, anxiety, loneliness, depression, despair and hopelessness to inner peace, intimacy, self-confidence. Yet, only two people apart from himself know about this transformation — his partner and me.
Herein lies the irony of depression within our society. It is widely accepted that depression is very common. Depression is at the forefront of GPs' and psychiatrists' diagnostic categories. But for all this seeming focus on depression and mental health problems in general, there is little discussion around the experience of depression. People experiencing depression frequently feel they cannot talk about this in public, for fear of judgement and alienation.
The current preoccupation with interpreting mental health problems as medical illnesses may seem plausible. However, this approach is problematic on many fronts. Contrary to the expressed views of many doctors, the links between mental health problems and biological causation remains a hypothesis; it is an unproven theory.
No person, anywhere in the world, has ever had their supposed biochemical brain abnormalities confirmed with any form of laboratory testing. It seems to me that the only truly scientific approach is to remain open to this possibility, whilst ensuring that all other legitimate possible causes and approaches to mental health problems receive appropriate attention.
One serious consequence of the medical preoccupation with biology and illness is that mental health problems tend to be treated in a vacuum, as if they have little or no relevance or input into the person's everyday life. It seems to me that this is a very unrealistic approach to mental health and mental health problems.
There is little evidence that all this medical focus on depression and mental health problems is achieving results. Prescription rates for antidepressants have risen consistently and substantially over the past 15 years, since Prozac and the other SSRI drugs came on the market. Approximately 300,000 people in Ireland take antidepressants. Surely, with so many people taking them, and given how enthusiastically doctors have been prescribing them over the years, it should be relatively easy to establish beyond all doubt that these drugs are making a difference in the ‘fight' against depression.
Surprisingly perhaps, there is little or no evidence of this. Suicide, said to be a consequence of depression, remains a social scandal of enormous proportions despite the ever-increasing prescribing of these drugs. Hospital admission rates for depression, outpatient attendances for depression and rates of disability from depression have risen steadily over the past 15 years. If antidepressant drugs were as effective as we have been told they are, all of these indices should be decreasing, not increasing.
In fact, clear evidence has been emerging in recent years that the value and effectiveness of these drugs have been oversold considerably. This is not to say that medication has no role. Many people report that medication has helped them greatly. Some people say that medication was essential for them, that it was a life-saver for them. However, mental health services which provide little other than medication are inherently seriously deficient.
If we are to stem the tide of suicide, depression and mental health problems which engulfs Ireland and other countries, a major overhaul of the intervention and support services for depression and mental health services is urgently required, as is a major review of the nature of mental health problems. In my opinion, what is called for includes greater input from people experiencing depression; a much greater focus on the experience of depression and on the process of recovery. I believe that Depression Dialogues can be a valuable resource, helping people to share their experiences and realise they are not alone in their experience.
Dr Terry Lynch is the author of Beyond Prozac: Healing Mental Suffering Without Drugs. He lives in Limerick, where he practises as a psychotherapist. Here are his own words explaining why he lost faith in the way he had been trained to practise medicine:
‘I qualified as a doctor in 1982, from University College, Cork. Following training, in 1987 I began working as a GP in Limerick and continued until 1997. For the first few years of my work as a GP, I embraced all I had been taught with enthusiasm. Sometime around 1992, I began to question much of what I had been taught. The impetus for this questioning came through the people who walked through my surgery door, and concerned mental health problems in particular.'
