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 may have been a psychiatrist, but I was unable to think with any clarity. I sank down into the sofa in front of the fire and wept. I watched the flames and listened to the fire crackle, yet was strangely unable to feel any warmth. I was just cold and lifeless. I was forced to admit at last that there was something seriously wrong with me.
I didnâ€™t know the answer â€“ I still donâ€™t. This is who I am. I cope most of the time; I am well for months, sometimes for more than a year, but there are recurring periods when the world seems a darker, more hostile and unforgiving place. I am a person who gets depressed. In the past 30 years I have listened to many stories of depression and despair, and learnt a great deal from the people who have shared their lives with me. Although their experiences have resonated with my own, I generally havenâ€™t revealed my own history of depression.
Whenever I havenâ€™t been well enough to treat others, I have sought help and worked at achieving my own recovery first. Yet, I believe my experience of depression has helped me to be a more humane, understanding therapist.
When you are caught deep in the jaws of depression, recapturing a sense of hope seems almost unimaginable. Low mood colours the way we see our lives and clouds our judgment, not only about others but most particularly about ourselves. It is hard to think positively, as others often insist when you consider yourself to be completely worthless.
It was never the patients who kept me awake at night, but my interactions with the system I worked in. At times of stress I become increasingly fearful and anxious, and when I feel as though I am losing control over my life, despair soon sets in. That sense of being in charge is important to me. Yet I also know that this need to retain control can prevent a person from seeking assistance when they really need it, since accepting help can also be seen as relinquishing power over oneâ€™s own life, of giving in and losing personal freedom, which can feel very frightening indeed.
Even as a medical student in Edinburgh, I remember waking early each morning, listening to the milk float clattering along the cobbles and the swell of the rush-hour traffic beginning in the distance, dreading the start of another day.
My life was charted out in blocks of time, each specifying a goal I must achieve. If I failed to attain the daily objective, I might lose more time by obsessing over how to rewrite my work timetable. I became enslaved by white sheets of paper spreading out over the floor.
I hadnâ€™t always wanted to be a doctor. The idea came to me quite suddenly around the age of 15, when I realised that I didnâ€™t want to be a biology teacher, which was the direction in which I thought things were heading. I was, quite simply, good at science, the first member of my family to go to university and, when I wasnâ€™t feeling anxious, determined to make the most of the opportunity. The problem was that I did feel anxious about it, quite a lot of the time. Anxiety became my default state of being.
Sometimes I forgot to wash or dress if I didnâ€™t have to leave the house, which was often the case as the days went by. I crawled into the revision lectures but avoided having conversations with anyone. From a distance I observed the ebb and flow of my classmates in and out of their conspiratorial circles. I was sure they knew all of the things about me that I didnâ€™t want them to know. And I was convinced that they knew I was going to fail.
My increasingly erratic behaviour puzzled my then husband. â€œWhat the hell are you doing?â€ he asked one night, as I sat rocking backwards and forwards in the chair by the fire. â€œIâ€™m trying to get rid of the pain,â€ I muttered.
The tension in my gut made eating difficult, and I woke in the night racked with colicky pain that I could only relieve by rocking, just as I remembered my little brother doing as a child when he was upset. â€œDonâ€™t you think you ought to go and see the doctor?â€ my husband asked. â€œThereâ€™s nothing bloody wrong with me,â€ I screamed back across the room. But he could see I was afraid.
After I qualified as a psychiatrist, I was still prone to depression. Sensitive or too thin-skinned? I was able to give the appearance of steel and ice but this was, and still is, just a performance; inside, beneath the surface, I was jelly and water. I was too easily wounded and my interactions with others, especially my family, had left their emotional scars.
I had always tended to dwell more than I should on the significance of what others said or did; I would mull over difficult conversations in my mind long after they had finished, hurt by things said without any cruel intention.
I often found myself wanting to please other people in order to be liked, but then resenting how this prevented me from doing the things I wanted to do. I would say something hastily in irritation, only to regret it later, and then begin the cycle of ruminative thought all over again.
An acquaintance once asked me why I didnâ€™t see more of my mother. It was very difficult to tell her that my mother and I could not tolerate each otherâ€™s company. Although the general belief is that â€œall mothers love their childrenâ€, I wonder why people make such assumptions when there is so much evidence in the world to the contrary. In moments of generosity I could believe that my mother probably loved someone who looked and sounded exactly like me. The problem was that I could never be that person and retain my sanity.
Instead, my mother and I engaged in a kind of prolonged warfare, each of us not receiving from the other what we really wanted and inflicting more punishment in return. I no longer belonged with my family; it felt as if there was no room for me there.
I realise now how it never provided the kind of warm, secure and loving home that many of my friends seemed to have had. I didnâ€™t feel there was a real place for me anywhere, except at work, on the ward. There I had an identity and a purpose, and my history was unknown.
No one knew I was my motherâ€™s â€œungrateful childâ€. I could continue to create the new persona that I had been constructing since medical school. I was efficient, caring and, outwardly at least, quite tough. I was succeeding in my career and I had something crucial in common with my patients: we had all been wounded by life.
By the time I reached my thirties, I began to understand that if I wanted to overcome some of the problems I faced in my life, and be more successful in my relationships, I was going to have to learn how to manage my fear of loneliness and tolerate my own company. I also began to recognise how fear of loneliness had prevented me from addressing the shortcomings of my own marriage after the death of my father. My life too had been emotionally â€œon holdâ€ â€“ a future postponed. After the end of my first marriage, I understood the pain of loneliness â€“ the terrible fear that I would be on my own for the rest of my life, that there would come a time when I would never again experience the physical warmth of a sleeping lover by my side in the morning.
I was scared that I would be one of those old women who die alone and are found in their kitchen having not been seen for several weeks. Like many of my patients, I was afraid of feeling isolated and cut off from the rest of the world. Isolation, loneliness and depression are closely related to each other. Being apart from others can contribute to us becoming depressed and also prolong our recovery. The problem is that when we become depressed, we often begin actively to isolate ourselves from others, because itâ€™s difficult to talk, enjoy company or trust anyone.
Compulsive behaviour has been something only too familiar to me. I grew up with a brother with obsessive compulsive disorder. I recall how a particularly painful relationship had finally come to an end some years ago. I remember how nothing seemed more important than just trying once more to speak to my former lover; how I hoped that he, my lover, would change his mind and come back to me after all; how I hoped that he was thinking about me, missing me as much as I missed him. I was convinced all of my friends were wrong â€“ I knew he really cared about me and that I just had to try once more.
I was prepared to beg this person, who had rejected me so painfully, to come back to me. I remember calling him. I held my breath for a second. â€œHello?â€ he answered. â€œIâ€™m so pleased you answered. I had to speak to you.â€ There was a silence. I could hear his breathing. I sensed his impatience, but I couldnâ€™t help myself. â€œWhy are you doing this to me? We know itâ€™s over and now you ring me here.â€
It was a kind of love, but it was far from kind. This tortuous pattern repeated itself in my life more than once. I had a series of relationships with unsuitable men who seduced me with their charm, but rejected me when they discovered that beneath my veneer of independence and apparent self-possession there was another â€“ much less confident and sometimes needy â€“ individual who was often anxious and uncertain of herself.
I was stuck in the vicious cycle so often I can still narrate each step. You start to hope again. You watch him all the time, and try to please him. You cannot afford to be yourself in case he doesnâ€™t like you â€“ until the day arrives when he doesnâ€™t seem to like the â€œother youâ€ either, the person you are trying to be.
Your other self, needy and voracious for both love and tenderness, seems to have revealed herself despite your efforts to suppress her. You know itâ€™s over, but you canâ€™t bear it. You love him. You hate him and you hate all men. You think about him all the time. You canâ€™t sleep. If this is love, you donâ€™t want it and yet you really do. But he doesnâ€™t want you. He says he has fallen out of love with you because you are â€œno fun any moreâ€. He walks away, but you beg him to hurt you one last time.
Like many people who have difficulty trusting in the fact that they can genuinely be loved, I chose men who were not available. These were married men who could not give me what I needed and with whom I simply repeated the experience of rejection, which confirmed my negative self-perception.
Moreover, I knew it was even more important that I prevented myself from driving a decent and loving man away with my sometimes difficult and unpredictable moods. This recurring compulsion to feel the pain of rejection has its origins somewhere in the complicated relationship I had with my parents, in particular with my father. I remember how I could feel the tears welling up in the corners of my eyes when I spoke to my former lover that last time on the telephone. I knew I was becoming pathetic, but I couldnâ€™t help myself.
â€œI just need to hear your voice; my life seems so empty without you,â€ I said to him. There was a pause, then he replied, â€œDonâ€™t call here again.â€
There have been times when I have felt low in mood and physically exhausted, as though there was a weight bearing down on my chest, which prevented me from moving. On other occasions, it has seemed as though anything and everything is possible. At those times I did seem to lose control and retreat from reality. It was then that the suicidal thoughts would return, although by then usually only fleetingly.
The life events that trigger an episode of depression usually have one important thing in common: they are concerned with loss. In a person who is vulnerable, perhaps because of their early life experiences or family history, this is often the case. Sometimes it is too painful to begin to address and manage the thoughts and feelings connected to what we have lost and we simply get stuck; we ruminate about the past, going around in circles, unable to let go and move on.
When I once again reached a moment when there seemed little point to living my own life, it was still unexpected, despite what had happened in the past. I ignored the warning signs: the early-morning wakening, the sapping of energy from my limbs, the increasing irritability and anger. There had been a series of losses, each of which undermined the tenuous hold I had on my sanity. A good friend, Sam, died in a tragic mountaineering accident. And then, another loss.
â€œHave you heard about E?â€ a psychotherapist colleague rang to ask me. E was a therapist I had seen for three years. She knew I had seen E as a patient in the past, but she did not know for how long I had depended on him or how important he had been to me.
â€œI thought about you. I didnâ€™t know if you knew.â€ â€œKnew what?â€ Once again, as had been the case when I had heard of the death of my father, there was little or no warning to prepare me for the bad news to come.
â€œE drowned himself in the river last week. Heâ€™s gone. Heâ€™s dead. I canâ€™t believe it.â€ I could hear the tears in her voice, but I could not speak. I slumped into a chair and simply tried to keep breathing.
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 persona non grata in the circles in which he had been local aristocracy as a senior therapist. I knew little about what happened to him. Now I would never see him again.
My response to these events, as in the past, was to work even harder, with ever decreasing efficiency. This time I did not draw up plans on paper to master my problems, but ruminated ceaselessly instead about the mounting difficulties at work. I had allowed myself to hope I would never feel so unbearably anxious and fearful again, but the bleak, hollow feeling returned. This time I felt exhausted, weak and dead inside.
â€œSo, do you want to try an antidepressant?â€ my GP asked me the first time I told him the story of my recurring symptoms.
I liked my doctor. However, I wasnâ€™t sure whether he really got what it was all about for me. I felt I was living on the edge of the abyss and sometimes, I suspected, I wilfully threw away the rope.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 â€“ an examination to pass, a piece of work I had to finish â€“ 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.
I also did not tell my doctor about the terrible weight pressing down on my chest, which became lighter when I cried but only for a while. My body felt as though lead had seeped into my blood vessels and bones, slowing down my whole being.
I called a colleague and friend, Susan, who was one of the few people I trusted to give me an honest opinion of my mental state. She asked me to come and see her that afternoon. As I feared, it was not long into our conversation before she approached the death question. â€œI have to ask this,â€ Susan looked directly at me with her clear grey-blue eyes. â€œHave there been times when you have felt so bad you have thought life isnâ€™t worth living?â€
â€œYes,â€ I replied. There was a sense of relief to be able to talk about it, but it wasnâ€™t easy to find the words to describe such a painful feeling, and I could not stop sobbing as I replied. â€œSometimes when Iâ€™m on the motorway â€¦ driving â€¦ I just canâ€™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 donâ€™t think I really want to do it â€¦ but I canâ€™t â€¦ I canâ€™t get it out of my head. I canâ€™t stop thinking it.â€
â€œSo you know what you are describing,â€ she said, as she stopped writing for a moment.
â€œDo you think these might sometimes be obsessional thoughts?â€ I had talked about my brotherâ€™s illness, and the delay in beginning to grieve for my father. The past I tried so hard to leave behind was catching up with me. I told her about problems I had been having at work.
â€œDo you think Iâ€™m paranoid?â€
â€œI think,â€ Susan paused for a moment, â€œthat you are really very ill, and Iâ€™m so pleased you got in touch and came to see me. I know how difficult it must have been for you.â€
She looked at me. â€œI can tell you what I think. I think you have a severe depressive illness. But what do you think?â€ Susanâ€™s words did not come as a complete surprise. In a similar way, my psychiatrist went through the different options with me. She was also sure that I would benefit from antidepressants. The problem was that I had hated taking them previously.
I was nervous about taking new medication, and over the first few days I felt quite nauseous, especially in the morning. I learnt 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 â€“ most distressing of all for a person who had always surrounded herself with books â€“ I felt unable to even open one of them. An increase to 40 milligrams didnâ€™t make much difference.
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, because it improves mood fairly rapidly. The problem is that â€“ among other more unpleasant things such as kidney disease â€“ 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 I could never define. I checked for the awful weight on my chest, since it usually caught me in the moment between waking and full consciousness. But this time it didnâ€™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 hadnâ€™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. Could these improvements be connected to the tablets I had been swallowing? I found it hard to believe. Although I knew that tablets could change your perception of the world, I didnâ€™t want to believe the solution to my problems could be so simple â€“ 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 donâ€™t think I would have survived to wonder again at the sharp, fresh beauty of a spring morning. Iâ€™ve learnt a great deal about depression in my life. I know much more about what causes it and its consequences than I did in the past. I can help people who suffer from it.
In the past decade I have experienced a relapse of my depression every couple of years or so. 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 played an important role.
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.