9. The Optional Illusion.

Facing my inquiry panel.

It is bank holiday weekend and I am waiting for the news to show the usual rioting in Brighton, as rival gangs of philosophers – down from ‘the smoke’ – fight each other with motorcycle chains. The battle between Positivists and Constructivists continues more ferociously than ever.

It’s all to do with the way you like to see Reality. The R word is an issue for mental health specialists, since mental disorders are loosely defined as a breakdown in reality testing. Positivists like to measure reality with a ruler, whereas Constructivists like to feel it through their sensory experiences.

Positivists are quite certain you have a dining room table made of wood, whereas Constructivists aren’t even certain they are in your house at all.

Having watched the Matrix, there has to be a chance that we are all just brains in buckets being fed information via the higher number Sky channels.

There are times when Positivism is essential, like measuring the dose of insulin and checking the blood sugar level, or flying a jumbo jet. When it comes to appreciating a restaurant or a book, it is probably better to judge the overall experience than rate it with a star scale.

Consider this experience: a car goes past you. There is a large dog sitting in the passenger seat, facing forwards. The dog has the window slightly open and a serious look on its face.

Why is that funny?

The humour is at the expense of the dog. It thinks its a human. It probably thinks it is driving the car. Sadly, the dog probably does not possess ‘theory of mind’. It is happily oblivious to its station in life, which is having no rights whatsoever and certainly no vote, not even for the European parliament.

Pets are big business in the UK. How much of the supermarket is devoted to pet food? How much greenhouse gas is produced by pet related activity?

What are pets actually for, if we exclude working sheepdogs and guide dogs?

OK, horses are arguably a form of transport. And I believe ferrets play a vital role in carrying cables through underground pipes. I think there are mites that play a role in cheese production, oh yes, and the little worm that goes in Tequila, though I’m not sure what it does.

I ask just to get some comments from pet owners and tequila experts.

If the answer is ‘for company’ then I’m thinking do pet owners display the same kind of obliviousness as the dog in the passenger seat?

Treating dogs and cats as people is a strange distortion of what animals really are. But in a way, we are all like the dog in the passenger seat. We construct a view of the world, but the view has many blind spots, illusions and distortions.

If the world was presented to the senses in a completely clear and unfiltered stream, it would probably seem unbearably harsh. Nature can appear very cruel if we don’t give it a bit of positive PR, which is when it becomes all things bright and beautiful.

You would like more friends so you create an imaginary friend in the shape of a grey cat. It has a droopy moustache and its name is Zorro.

How many movies, how much merchandising, has gone into ‘anthropomorphism’ – projecting human characteristics on to animals?

The brain seems to have a tendency to attribute human like characteristics to natural phenomena and even inanimate objects such as steam engines and curling tongs, so its not surprising that creatures with two eyes and four limbs are treated as though they had finer feelings.

How much are you really empathising with a dog if you regard it as your loyal friend?

By now you have guessed that I just don’t ‘get’ animals as pets, and not much really as food. Some time soon I hope the genetic engineers will be able to make fillet steak from cell culture on a giant loom in Milton Keynes, and our cows (and horses) can relax again.

Animals have a key role in the eco system and they are incredible in how they can look and behave. They are magnificent creatures. I nearly said they are magnificent pieces of machinery (they are). I love Disney films, and Tom and Jerry, but I think I have placed these firmly in the Fiction section.

I just don’t think Toads can really buy motor cars and get put in jail for dangerous driving. Not even in Hartlepool, where they allegedly hanged a monkey having mistaken it for a French spy.

Just to leave the pet lovers alone for a while, let us turn our attention to motorcycles. From a positivist perspective we find that these accelerate very fast in a straight line. They are very cold and noisy, don’t really go round corners as fast as cars, use more petrol and tyres than cars, and are quite dangerous.

That’s if you actually ride them outside their safe operating radius of one mile from Cafe Nero. As a form of transport they get only one star.

But to counteract this, using a constructivist method, we temper our initial experience of noise, cold and danger with a range of romanticised imagery borrowed from Marlon Brando, Bruce Springsteen and Ewan McGregor, that sets motorcycling into a grainy black and white arts movie with a working class hero.

So Pets. And Motorcycles. The fantasy does not match the reality. We use ‘sentimentalisation’ to reduce the discord between the ways things are and the way they really ought to be. War has probably been sentimentalised more than pets, and slightly more dangerously.

And luckily, there is an absolutely huge industry whose job it is to help us not see things correctly, spanning politics, advertising and business. Advertisers construct chains of feel good imagery and attach them to our perceptions. Yogurt and Skiing, for instance.

In the motor industry engineers try to reduce what they call ‘NVH’, noise vibration and harshness. Sentimentalism is a defence against NVH in the personal environment. It’s a cosy room with cats and cuddly toys, where Liberace plays Candle in the Wind.

Consider this statistic:

Of the 26.4 million households currently in the UK, 7.6 million – or 29% – are made up of only one person, with the growth in single occupant households owned by the middle aged creating extra demand for homes.

There are many reasons for this social trend, but it seems we are becoming increasingly intolerant of living with other people. This trend has also been termed ‘schizoid society’, where we all inhabit a little bubble, and our only contact with others is as spectators.

Such a process was well anticipated and described by Isaac Asimov, in his novels about the planet Solaria. People, in proximity, just cause too much NVH. People – most people – just wouldn’t fit in the yogurt commercial.

Some of the most attractive, well thought out and effective types of therapy have devoted themselves to seeing the world more carefully and sensibly. Some nice examples include rational emotive therapy, now called REBT; personal construct psychotherapy, and Karl Rogers’ person centred therapy.

Interestingly these were all developed in the 1960s and 70s. Sadly none of them are really available much now, not in a pure form at least, though they continue mainly through strands of CBT and counselling.

I don’t think anyone has invented an anti-sentimentality tablet. Nor can I find a sentimentality rating scale to measure its effects. The lifestyle advice is relatively simple however.

Avoid sending cards for anything apart from birthdays and Christmas. Better still, avoid sending cards at all. Avoid most of Steven Spielberg’s output, and anything with James Stewart in it. Rationalise your yogurt buying to the 1000g ‘Eridanous’ pots from Lidl.

Sentimentalism is a kind of emotional clutter. There is a lot written about ‘decluttering’ your house, most of it rather obvious. First order a skip, then rescue ten things you really need.

Not you Tiddles.

8. The age of Sprocket Man.

Is the modern world inherently toxic to our bodily systems? Niall Ferguson included Work Ethic as a killer app for society. It is certainly a killer, but in a more literal sense.

The body uses countless timing devices to regulate itself. Obvious examples are the night and day cycle, the heartbeat and brain waves.

Systems theory teaches us that everything has a point of equilibrium or natural balance. Most things have a natural frequency at which they like to vibrate. Some cars like to cruise at 50 mph, some like to cruise at 90 mph. Generally, the more German the car, the faster it likes to go.

Many systems have a feedback mechanism of some kind that puts them back to their default setting. On the road system, large potholes have been left like landmines to deter overenthusiastic driving. Inspired by the ‘safety car’ concept in Formula 1, our government has paid an army of older gentlemen to drive at a constant 42mph all over the country, to keep speeds down. As a uniform, they wear trilby hats. These are only worn when actually driving at 42 and never outside the car.

Farmers have received grants from the EU to bring their otherwise redundant farm machinery out onto the major highways at peak times, similarly to check undue haste.

In our neighbourhood we have learned to beware a vehicle we call ‘the Stealth Renault’. Painted black, this innocuous 1980s model is driven by an extremely old person (or a person disguised that way), in second gear at a constant 30 mph. His trick is to give you the impression that he will stop or is stopping at your pedestrian crossing.

He never stops though. Like Sandra Bullock in Speed, he maybe believes a bomb will go off if he drops to 29.

He is a road safety bogey man. He never ratified the green cross code. He is there to teach children never completely to trust traffic lights. He may in fact be a dummy, the car actually being driven by remote control from a university psychology lab, as part of a learned helplessness experiment. Or maybe by the authorities, to keep us a little on our toes.

After all, we may be getting a bit complacent. Such close encounters with terrorists like Stealth Renault are relatively rare nowadays. It is surprising how routine most activities have become. The post office queue stands patiently, First Capital Connect arrives on time, the Sky box records your favourite programs. I appreciate that other societies and parts of the world are different, but the UK, with the possible exception of Doncaster, has adopted a ‘no drama’ policy.

Isaac Newton taught us that every action is met by an equal and opposite reaction. Every time I turn the heating control down another person will come and turn it up to a point slightly higher than it started originally. The body has a similar system in the hypothalamus, which can be used if thermal underwear is not available.

In larger systems, such as the NHS, an attempt to make a change will be resisted with significant force. Employees in large organisations tend to work like small cogs in a gearing system. If the small cog gets out of line the whole gearing system will crush it back into place, a few splines missing, but still turning.

A lot of ‘choice architecture’ is set up this way, large systems with high moment of inertia. Franchised models and low variance operating schedules ensure you will find the same shops and restaurants in every town.

Why not put the Hugo Chavez T shirt away and just coast along with things? People are living longer after all, and the television screens are getting bigger, sharper and cheaper all the time.

Why is it then that so many people seem to be unhappy? A recent survey by Unicef suggested that children in the UK are among the unhappiest people anywhere.

‘Pressured and commercially vulnerable, our kids are the most miserable in the industrialised world’ spoke the Guardian. People have blamed a mixture of possible causes, from inequality to the demise of the nuclear family.

Blur titled an album ‘Modern Life is Rubbish’ and I find myself quoting that to people whenever there is a spectacular system failure, such as getting stuck in a 20 mile traffic queue, or trying to pay for parking using a mobile phone.

Another line I find myself saying is ‘everything is relative’. There are many compensations in modern life.
It is the best time ever for ease of communication. Even Captain Kirk did not have a smartphone.

Food is at once the best and the worst it has ever been, depending on whether and how you choose your ingredients. I went to the Turkish part of London yesterday and had an amazing breakfast for £5.

A car made in 2013 is undoubtedly, objectively and measurably superior to a car made in any earlier period. It is faster, stronger, safer and more economical than before, and it is never mustard or beige coloured.

This is probably not the best period for music composing, which peaked in the classical period. But it is the best time for listening to Beethoven or Mozart, or any other music, because we have fabulous sound quality in concert halls and from hi-fi systems.

The best novels ever were probably written in the nineteenth century. But we can read them all free now on a device that weighs half a pound.

The renaissance period gets the prizes for painting and sculpture. But they did not have antibiotics or dentistry.

Teaching was probably better 50 years ago than it is now. And, as we know, History ended in 1989.

Different systems peak at different times. It s hardly likely that all systems will peak at the same time. That’s having your cake and eating it; or finding the M25 is completely clear all the way round.

If you happen to be lucky your system suits your natural frequency, and you will run smoothly. Your system will mesh with other systems and you will spin freely on your bearings.

If you are unlucky, like most UK children apparently, you are not in tune with your system.

For instance we know that children function better if they start school at 10 or 11 am, but our local school makes them start at 8am. The problem for children is that their system runs subordinately to every other system, so that they are made to fit in with adults rather than the other way round. The more your system is subordinated to others the less chance you will be in your own element.

The advancement of the system devoted to economic productivity has marginalised children, along with the old and sick, to the bus replacement services of life.

Children cannot vote, after all. They are just lucky that they don’t have to sweep chimneys any more. Worse than chimneys though, we have breakfast club and afternoon club, not to mention the dreaded school bit in between the clubs.

David Cameron said today that he wanted to place himself on the side ‘of hard working people who want to get on in life’.

What about those people who yearn for a life of recreation and entertainment? Shouldn’t all those machines and mechanised systems have made it possible not to work so much?

A big category of mental health diagnoses is the so called Adjustment Disorders. These come in various forms, including depression and anxiety. They are usually mild and transitory and reflect what many people loosely refer to as stress.

They can be seen as a wrench caused by a change of system, much like ‘frozen points at Guildford’ delayed Reggie Perrin by 11 minutes each morning. If frozen points cause a complete derailment, then the Adjustment Disorder is upgraded to a more serious diagnosis like Depressive Episode. A lot of depressive episodes also seem to follow adverse, or even positive, life events, which have caused a crunching in the gears.

The concept of mental health problems being stress related is attractive and easy to understand. But it only tells a part of the story. Most people are robust when it comes to negotiating changes.

Perhaps they have a wider tolerance to a range of operating conditions, so they are more often in their comfort zone.

A comfort zone is supposed to be a behavioural state where we are happy and confident and working reasonably well.

Some people work on their comfort zone more actively than others. Attributed to golfer Gary Player is the phrase: ‘the harder I practice the luckier I get’. Specifically referring to shots played out of sand, Player mastered the shot to the extent that he was equally comfortable in the bunker as on the grass.

Round about the time Player made that quote, in the sixties, psychologists developed the theory of Learned Helplessness.

Psychology nowadays keeps a bit quiet about these sorts of experiments -suffice it to mention the words electric shocks and dogs.

Later on, with the move from behaviourism to ‘cognitivism’, the negative effects of helplessness turned out to be more to do with a person’s pessimistic explanatory style than the actual experience of not being in control. This led to the idea of hopelessness, and the relationship of that state to suicidal thinking.

The issue is not so much whether we really have control over what happens to us, but more whether we think we do.

Studies in Ireland have shown that patients with Depression like their therapist to take an upbeat and optimistic stance with regard to whether and how much recovery will take place.

I remember a moment when, as junior doctors, we observed the arrival of a very senior colleague, in a severely dilapidated Ford Escort. It was trendy at the time for the psychotherapy – orientated type of psychiatrist to drive ‘crap cars’, such as this one or the Austin Maxi (mustard colour). As we watched, another SHO colleague put this scenario to me:

‘Imagine you’re in the depths of despair. You have been tried on every type of antidepressant. You’ve tried counselling and psychotherapy. You’ve had herbal medicines and homeopathy and transcendental meditation. The GP finally arranges a visit from the leading specialist at the teaching hospital. You watch through the window, and you see in the distance the Professor arrive in his Escort, which has large furry dice dangling from the mirror. Is that not the moment when suicide seems inevitable?’

Harsh perhaps. Equally, people might like to see someone eminent arrive in a non pompous vehicle like a 2CV covered in stickers or an original Beetle with vase. I can’t remember any specific training on what vehicle to drive, although an older colleague insisted that consultants should only ever have Michelin tyres, ‘never Goodyear my boy’.

To return to the point, the feeling of having a choice matters a lot, even if in the wider scheme of things, the biggest choice we really get is between Diet Pepsi and Pepsi.

The comfort zone is largely a place where we choose what happens to us. A lot of people want to move us out of our comfort zone.

It’s true that we will be more productive if we are challenged just a little. Coaches know that a mixture of support and challenge can bring about superior achievement. The same approach can work well in therapy, for instance treating a phobia. If the comfort zone has got too narrow then it needs to be carefully increased.

Unfortunately, in most organisations, the challenge is greater than the support. The pressure is always on to squeeze a little more out of the system. Supermarkets want to get the milk off the farmer for a few pennies less. The farmer turns the cows up to 11, giving them more food, or playing them some Led Zeppelin at milking time.

The effect of the larger and more dominant system on your system is felt as disharmony, or being slightly behind the beat, or as a little ping in the ears. Your system might be different.

Interestingly, this is exactly the kind of disorientated feeling that makes us purchase something – retail therapy – or consume some alcohol – drug therapy. The work ethic is all about ‘must’ ‘should’ and ‘ought to’.

It all depends whether we want to make superior achievements or just be happy with what we have. It’s not a choice we seem to get very often. Even the illusion of choice is worth a lot though. Turkish breakfast. Mozart. Thomas Hardy. And, today I think, Diet Pepsi.

The comfort zone is equivalent to driving at 50mph.

It’s better than 42. It might even be better than 52.

PS: It looks a bit like this one.

7. Killer Apps of the Mind.

A cultural education (picture by Roland Topor)

There are several types of therapy for Depression. In one way or another they are directed at improving insight. Whether improved insight translates directly into recovery is a different matter. Also we are assuming that better insight is always a good idea. That might not suit certain vested interests and power groups who need us at the grindstone all day, in the pub all evening and shops all weekend.

There are quite a few logistical barriers to psychological treatment – finding it, getting there, sticking with it. Recently a number of computer programs, or applications, have been designed to help, with names like Beating the Blues and Fearfighter. Mostly these have been presented by IAPT therapists in health centres or GP practices. They can be accessed directly by users at a price, but its only a question of time before cheap or free apps become available for home use. These applications have been given a cautious welcome by experts such as NICE. People who are used to modern computer gaming will find them a bit pedestrian. I hope we can rely on the software industry to pump them up.

Professor Niall Ferguson recently presented an account of modern history attempting to explain the rise of western civilisation. He used the analogy of ‘Killer Apps’ to explain why certain societies had prospered.

Competition, Science, Medicine, Property Rights, Consumer Society and Work Ethic: these were the processes that had brought about Western Civilisation, he argued.

Commentators say that Ferguson has misused the term ‘killer app’, which has, or used to have, a particular meaning in the computing world, not just an analogy for ‘vital’.

A killer app was supposed to be an item of software unique to a particular piece of hardware. So if you wanted a spreadsheet or desktop publisher you had to have a Mac.

Strange that Ferguson, an academic historian, tolerated an historical inaccuracy in the use of terminology, for poetic licence. The recent history of technology is probably more interesting, important and possibly bloodthirsty than the Tudor period. Still, the killer app analogy caught people’s attention, which was probably what he intended.

History wasn’t my favourite subject at school. In fact, school utterly killed History for me; too many dates and royals. I was glad when Francis Fukuyama published his book ‘The End of History’ in 1989, though for me History ended in 1973, with the damp squib of an O Level exam. After Fukuyama published his book I fully expected all the History departments in schools and universities to shut down like the coal mines, their job finished. Instead of which we saw the emergence of Time Team and Dan Snow.

Since apps had not been invented in the 1970s, I can’t blame my History teachers for not using this illustration, though I can blame them for never using gimmicks at all. Aside, that is, from Mr Hockenhull’s epic 8mm movie, reenacting the Battle of Hastings in Disley.

Still, it’s a slippery slope between education and entertainment, one that I personally would hurtle down on a Lidl trolley, but thats another story. The trick I suppose is using colourful illustrations to explain ideas without dumbing down the key message.

I am certain that Niall Ferguson has looked at all the information available and come up with the right processes that shaped prosperity, but does it help to think of them as Apps?

Apps, on the computer at least, are processes that run within an operating system.

There are certain aspects common to any system, operating or otherwise. There’s a whole theory of systems, which spans science from engineering to economics. So there is a whole range of analogies to be made between aspects of different types of system.

So it might make sense to use the analogy of an App in terms of processes in societies, small groups of people, or individuals, all of which are systems of a kind.

A system needs to define itself using boundaries. It needs to regulate its inputs and outputs. It needs fuel broken down to provide energy. It needs feedback control to maintain itself. The same features can be found in any type of system, large or small, with the possible exception of the Beko washing machine.

Freud had a surprisingly electrical view of how the mind worked. For instance,Freud thought the mind had a range of mechanisms to protect itself from electrical overloads, which are now called defence mechanisms. For instance a murderous impulse might have its energy directly countered, or projected onto another person, or converted into a physical disorder.

Some of these defences he thought were disastrous and some more effective and healthy, such as Humour, Altruism and Anticipation. We could regard Freud’s favourite defence mechanisms as Killer Apps (almost literally) in terms of dealing with extreme thinking. In terms of treatment options, Freud had something of a killer app in the form of Hypnosis, which he abandoned in favour of the technique of free association, which is like exchanging a Macbook Air for a Babbage Engine.

Killer Apps in the Mind? After all, the mind is genuinely a computer system, unlike society, which is a mixed bag of systems, non systems and mud.

In truth, many people have attempted to explain how the mind works, using simplistic models that involve two or three main components. Analogies like these tend to break down when we try to illustrate something so complicated.

Apps however have the advantage of being highly specific. I have one that merely turns on the phone flashlight. Yet there are others that tell me exactly where I am and how to get home. I have one that tells me my car is in Munich at the moment. Inkorrekt!

Just like Prof Ferguson introduced the idea of Killer Apps to spice up a massively complicated piece about the history of the western world, we might be able to use the concept to help us talk about mental processes without being hidebound by some overarching model.

We might be able to use the App idea to spotlight certain aspects of morbid thinking.Terms proffered by CBT therapists like ‘arbitrary influence’ and ‘selective abstraction’ never felt very user friendly.

Specifically, are there certain killer apps that could protect against getting depressed, or help a depressed person, if we could only download them to someone’s mind?

Abstract thinking, such as the use of metaphor, proverbs and analogies, helps us organise information. Using templates, such as lists, mnemonics,algorithms and ‘pathological sieves’, helps organise piles of untidy thoughts.

If we could load some of that onto a smartphone we could call it something like Meta4Works or ProverbBlaster. These are perhaps part of a larger software package we could call InsightFull.

I would also like someone to invent FrameItWider and AttributeRite to counter some common cognitive errors.

Mostly we need help to make better decisions. There is a growing interest in how decision making takes place, both in individuals and organisations. Books like Nudge by Thaler and Sunstein explain how the ‘choice architecture’ affects how people behave. The role of default options is surprisingly strong.

Zhan Guo, in a paper called Mind the Map, showed recently that the London tube map affects peoples travel decisions far more than their actual experience of making journeys. Sometimes the schematic map is nowhere near to scale geographically. Instead of using the map, we could use an App, putting in the destination.

Smartphones are getting smarter and people are – in some ways – getting dumber. Think of Arithmetic and Calculators. Could we not just hand over more of our troublesome thinking to a computer? Its precisely what we have done with arithmetic after all.

Already, or pretty soon for most people, navigating a car will be delegated to a GPS system. Its a set of decisions we can safely leave to an App. Now we have a computer system called Amazon, that can tell what I want before I even know myself.

Tesco know what kind of whiskey I would buy if only I had a voucher for £5.40 off the price. Not £5.30 mind you. £5.40.

Doubtless Tesco and Amazon are using a version of choice architecture to apply nudges to my behaviour. I doubt whether they employ clairvoyants or telepaths at Tesco, so I am guessing they are using a software application which clusters together things people like me have bought. Either that or I have misinterpreted that large phone mast on Tesco’s roof and those strange headaches I am getting.

Many decisions we make, particularly purchasing whiskey, should be delegated to a wiser system. When it comes to choosing a product or service, or even the way home, there are many sources of guidance.

Sadly, when it comes to the biggest decisions of all, we are often working too quickly, without enough information, without an App at all, or with a flat battery.There is a strong relationship between poor decision making and Depression, both in terms of getting depressed in the first place, and perpetuating Depression once it has begun.

That is why the Killer App we need the most is ChoiceMaker Turbo version.

I just used it at Tesco and ignored the whiskey offer. Like their trolleys, I have a mind of my own. Also, if I’m right they will soon up their offer.

I like the analogy of Apps, but it works better to illustrate a single mental process rather than model the mind as a whole, let alone whole societies. As a way of spicing up and developing CBT for a mass market, Apps could be the way forward, but we have yet to see a Killer App for Depression. Good news for therapists who don’t like anything called a tablet. The important thing is we continue to seek better analogies all round.

As Mr Hockenhull might have said, ‘the first two periods are Biology and IT, the rest is History’.

Or, after Fukuyama, ‘home early today’.

6. Getting Wiser using items you can find in your kitchen*

Its time for a quick win, before we delve into things any further. Today’s goal is becoming a slightly wiser person.

Our friends in Psychology have been very active over the last few years, explaining how the mind deals with day to day activity. There have been some great popular psychology books, such as Thinking, Fast, and Slow, by Daniel Kahneman, and Nudge, by Thaler and Sunstein, that have become bestsellers. A particularly useful scheme they have developed is the separation of mental activity into two types.

The first type, sometimes called ‘Type 1’ or ‘System 1’ or ‘Automatic’ is running slightly under the surface of consciousness. It deals with routine activity. Type 2 /System 2, or Reflective thinking, is the more conscious part of the mind, where we might actively try and process a task, like a piece of mental arithmetic.

It is usually tiring to use System 2 and we tend to avoid it. We use System 1 by default, and it can handle a surprising amount of day to day functioning, including quite complex tasks like driving a car.

Despite books such as ‘Nudge’ and ‘Thinking, Fast and Slow’ being best sellers, the impact of this new cognitive psychology has been surprisingly slow to affect how psychologists and other therapists work with patients. Though the automatic / reflective model seems to make sense, everyone is struggling with how the amorphous goo of the subconscious gets turned into the crisp waffle of a considered idea.

In particular, the type of therapies that are often called Cognitive Behavioural Therapy (CBT) often seem to depart in some ways from ideals we can infer from the Automatic / Reflective model.

For instance, one very commonly used type of CBT involves keeping a diary of negative thoughts. CBT fully acknowledges the presence of AutomaticThinking, the idea being that people suffering from depression or anxiety have Negative Automatic Thoughts. Just a little below the surface runs a downbeat commentary on the persons value and capability.

At a simple level such negative self statements are easily visible in everyday life. How often do you hear people say ‘I’m no good at maths’, or ‘I cant sing’ or ‘I’m not musical’? Depressed people tend to have a more negative set of thoughts, such as ‘I am useless’ or ‘People generally don’t respect me’ or ‘I can’t control what happens to me’.

An aim of CBT is to identify the negative thoughts by writing them down and considering them. In effect this means bringing them out of System 1 and into System 2. Yet we know that this is a process that generally people find unpleasant, even for ‘neutral’ tasks like trying to solve a puzzle or a maths question. And this is perhaps why patients very often struggle to complete the diary and homework tasks set by their therapist. Very often the patient fails to do the homework, relying on the mercy of the therapist at the start of the next session.

Of course, Freud and his followers would take a different view of such a process. First of all they would expect the truly negative thoughts to be buried deeply in the mind and not easily brought into consciousness. Furthermore they would expect ‘defence mechanisms’ or ‘resistance’ to digging these ideas up, since the mind buried them deeply for good reason.

So what? Thinking can take place at different levels of consciousness. Freudian and Cognitive Psychology would agree on that. And they would also agree that people struggle to bring thoughts from a lower to a higher level. Freud would say this is because the thought is emotionally charged and dangerous to consider – for instance a strong aggressive or sexual impulse. A cognitive psychologist might argue that the conscious System 2 is easily overloaded, much like the RAM on a computer. It is governed by a limited amount of ‘working memory’ which is easily exceeded. If asked to do more than one task at the same time, System 2 runs very slowly or stops altogether to get a beer from the fridge.

It has been clear to many CBT therapists that so called ‘second wave’ CBT, involving identifying negative thoughts and countering them is often unpopular with patients. Much of CBT has moved on to so called ‘mindfulness’ based techniques, which have imported an element of meditation or spirituality.

In embracing ‘mindfulness’ so enthusiastically however there is a danger of CBT exploding in all sorts of different and largely untested directions and falling prey to the usual cranks and charlatans normally confined to the alternative sector.

One of the strengths of CBT was that it attempted to measure its own effectiveness by using charts and scales. One of the weaknesses was that CBT became an incredibly wide church, to the point where the term ‘CBT’ became almost meaningless.

For instance CBT could span so called ‘psychoeducation’ or ‘activity scheduling’ which turned out to be fairly simple bits of lifestyle advice. Or it could mean 20 one hour fairly deep sessions with a Clinical Psychologist. So when someone tells me ‘I have had CBT and it didn’t work’ I am quite skeptical. (Just like I am skeptical when I am told ‘I tried lithium and it didn’t suit me’ or ‘I am allergic to bananas’ or ‘ I am dyslexic’. These statements always call for further enquiry and clarification.

I ask: How many sessions did you have? Who were they with? What did you do in the sessions? (Just talked), Did you have to keep a diary? (no), Did you have homework? (no), Did you have to try and look at your negative thoughts? (don’t think so).

Is there still some value in ‘old school’ CBT? By this I mean the process of identifying and challenging negative thoughts, using diaries and homework? Behaviour Therapists have a slogan: ‘if you do it you ‘ll get better and if you don’t do it you won’t’. That might hold for changing behaviours, such as facing a phobia, but how much can it hold for thinking differently? How much can the mind be forced, against the grain, to reflect?

Incidentally I have seen a very similar blindness in the fields of education and personal development, where ‘Reflection’ became all the rage. Reflection, at least if forced, is effortful and tiring to most people, even if they are not depressed and reflecting only about the price of carrots.

People will find any excuse not to reflect; the mind will default to System 1 whenever it can. The best reflection seems to occur when the mind is bored and free to wander where it likes, for instance, while you pretend to listen to the chief exec going on about drilling down into more challenging granularity, while you wait for the 8.23 at Platform 1b, or during the period between your parachute opening and avoiding the pylons.

Old school CBT has failed to recognize the difficulties people have in moving unexpected items into the bagging area of Reflective thinking. This is perhaps why most patients I meet prefer a counselling type approach, by which they often mean talking to someone until they feel a bit better. What we need is a better waffle iron to turn mental goo into considered thoughts.

Somewhere between the two approaches, CBT and Counseling, probably lies a better way of dealing with negative thinking. For instance I like the use of ‘mind maps’ rather than diaries, sketches or diagrams of what issues are affecting someone. Say it with cake if you want to.

Then there are little shortcuts. Management folk like these, e.g. 4 Ds. When presented with a problem you can Do it, Decide when to do it, Don’t do it, or Delegate it. (There are many variations on this one, as so many words begin with D, like Destroy it, or Dissect it, or Drop Dead Trying to Do it.)

Managers like little acronyms and mnemonics to bring in to solve a problem. Its something to focus the mind, or in other words, make the transition from System 1 to System 2 less noxious. Since we know System 2 is a scarce resource, which we are reluctant to use, we need to create a shortcut or scheme for using it efficiently.

Its sad that the road to wisdom turns out to be paved with acronyms and diagrams.

We used to have exams called ‘viva’ at medical school. They are the most feared type of exam for most people, as the format is one- on- one questioning. The problem is trying to operate the mind under very high anxiety conditions. The trick is to have a system to fall back on, something cast iron, like a grid, heated obviously, and teflon coated. Something to stamp out a well formed answer quickly and possibly even coat it with sugar.

If you are searching for a way of dealing with a problem, its very helpful to find a similar example, as Blue Peter would put it, ‘we’ve already done’. Like a Proverb for instance.

Proverbs have quite a poor reputation among psychiatrists. This is because – in my day anyway – we were taught to ask patients routinely to try and explain what proverbs meant. For instance we would ask them, ‘what does this saying mean: people in glass houses should not throw stones’?

Presumably this was meant to be a test of abstract thinking, and the correct answer I presume would be something like ‘beware of retaliation if you criticize someone’ or ‘ this illustrates the danger of criticizing other people for deficiencies you yourself might have’. The latter version seems to be intruding dangerously far into pot and kettle territory.

However most people gave quite poor answers, either ‘don’t know’ or overly ‘concrete’, e.g. ‘ the stones might break the glass’. That led us to the concluding that most people did not use proverbs day to day and were rather unfamiliar with the concept of metaphor.

Maybe people with mental health problems have a lesser use of metaphor in their thinking? Comments gratefully received on this one.

Another problem with proverbs can be the annoying existence of an equal and opposite proverb, such as ‘too many cooks spoil the broth’ and ‘many hands make light work’. Perhaps proverbs where there is no counter are superior and should be put in a premier league. Proverbs may not be used widely to support reflection, but that does not mean that they are not a useful tool. It just that the noise of modern life has drowned out a lot of wise words.

So, regarding CBT, or Proverbs, Diaries, Mind maps, or any other tools to help us organize our thinking, as SportsTalkExtra might put it: Lets not throw the dirt out with the bathwater.

Enough waffle for today.

*pencil, paper, pot, kettle, cooks, broth, beer, cake, waffle, waffle iron.

5. Knowing what to call things

An early classification system for depression, using cake.

Doctors and psychologists have invented a huge vocabulary of jargon. The downside of this enterprise is that non- experts are artificially excluded from participating. The upside is that at least we have a name for practically everything that might happen.

For instance – what do we call that thing – you know, in catatonic patients, where you pull their finger gently and you tell them to resist your pulling, but they follow your pull anyway without resistance, is there a word for that? How about mitgehen?

What about that thing where people mix up a coincidental event with a causal event? How about attribution error?

What’s that part of the wrist called at the base of the thumb? How about the anatomical snuff box?

How can we describe a loose pattern of findings that might include aspects of subjective history, observed behaviours and objective measurements, without necessarily implying a causal agent? How about a syndrome?

Depression has been described and categorised in so many different ways. We had reactive, endogenous, melancholia, major, minor, neurotic and many more types. We have dysthymia and neurasthenia, we have bipolar 1 and 2. As stated by medical man, comedian and philosopher, Harry Hill, and an excellent catch phrase and running gag: ‘you’ve got to have a system’.

We are often accused of inventing diseases, for instance ‘medicalising’ ordinary human problems such as poor attention. More accurately though, we try and classify problems rather than invent them.

Classification is hugely important to doctors, partly because we have a geeky fondness for lists and tables, but mainly because all of medicine operates through a process of Pattern Recognition.

What we call each pattern doesn’t fundamentally matter, but it may matter a lot for social or political reasons. For instance if we diagnose ADHD or Asperger’s Syndrome, rather than identify a certain kind of character, that might mean extra funding and help at school for someone. Diagnosis could make the difference as to whether someone who offended got sent to jail or hospital.

These issues largely flow from the way society is organised and what part the medical community has come to play within the processes of maintaining social order, rather than whether the Pattern is a genuine entity.

There are lots of ways of describing Patterns of behaviour. If there is a recognisable Pattern then there are a few things we need to say about it. Take a simple example, no, lets take a really complicated example – Anorexia Nervosa.

Psychiatrists have defined this illness so that there are three necessary components -the person should have lost a lot of weight, stopped having menstrual periods (if they had them before), and have a certain set of views about their body size. Both the first two aspects are easy to measure, the third one not too difficult to find out if the person will speak to you.

Anorexia seems to be both a valid and reliable diagnosis. By valid, we mean there is a real problem that we can identify and measure, by reliable we mean that people would agree on whether someone suffered from Anorexia Nervosa.

But is there truly an illness called Anorexia Nervosa? Only perhaps in as far as that is what we agree to call a certain type of problem. Diagnoses in Psychiatry, for the most part, are conventions between us regarding what Patterns should be called. Are there people we meet who seem to fit the criteria for Anorexia Nervosa? Yes.

Our health system, be it the NHS or private sector, will demand that we make a diagnosis. We have to use a system such as the International Classification of Disease or the Diagnostic and Statistical Manual. In the UK we tend to use the ICD10. That will give you a number code, such as F10, if you drink too much alcohol. The codes can be quite detailed if we use more digits, e.g. F10.4 if we drink too much alcohol, stop drinking for a day or two and get delirious. If we had an epileptic seizure during this we will get F10.41.

Are there people we meet who get Delirium Tremens some of whom have a seizure? Yes.

But why bother to label certain types of life problem and include them in a list of supposed Psychiatric conditions?’ I am not a number, I am a human being’, yelled Patrick McGoohan in The Prisoner. ‘Pigeon holing everyone’ – that is something Psychiatrists are accused of all the time, along with another favourite: ‘pumping people full of drugs’.

Ironically the interest in tightening up diagnosis in Psychiatry came as a result of a fascinating series of studies, the international pilot study of schizophrenia, or IPSS. The IPSS looked at the use of the term Schizophrenia in different countries including USA, USSR, UK, India and Nigeria. This study seemed to find that a larger number of people were receiving the diagnosis of schizophrenia in certain countries (USA and USSR). The American and Russian psychiatrists were calling a larger proportion of their patients schizophrenic.

At that time popular belief in the West was that the Soviets were falsely calling political dissidents mentally ill and locking them up in asylums. Whereas in the USA the disparity was put down to the way Psychiatrists traditionally understood the concept of schizophrenia.

It was soon recognized that it would be pretty difficult to do research into the causes or treatment of any disease if we could not even agree who suffered from it in the first place. Hence a huge amount of work sorting out a valid and reliable diagnostic system – DSM in the USA and ICD for the rest of world. The current versions – ICD10 and DSM4 are very similar in day to day use. So we can be reasonably sure that someone with Anorexia Nervosa in Milan has got a similar type of problem to someone with Anorexia Nervosa in Birkenhead. So if we find Cause X or Therapy Y in one place, it might prove useful in any other place. Such is globalization.

Much of the criticism of diagnosis in Psychiatry is based on what happens to people, and society, as a result of diagnosis happening. But criticizing diagnosis itself is as foolish as suggesting that it is impossible to classify colours of the rainbow or garden flowers.

The point is, sound diagnosis can be liberating as well as restrictive, it all depends on what we do with it. The danger is in poor quality diagnosis, or the misuse of diagnosis. These are the same dangers that occur with any tool, cordless curling tongs in particular.

How does this affect the depressed person in their kitchen?

Your subjective experience needs putting into words if you have to tell another person how you are feeling. You are free to create your own diagnostic scheme for Depression, but to be useful it needs to chime with someone else’s scheme.

In the case of Depression, even experts who normally know exactly what to call things, have failed to create much of a system. The ICD10 for instance gives up on classification much beyond the level of severity: Mild/Moderate/Severe. Its unlikely that mass protest and civil disorder will break out in response to this categorisation.

There is only one thing worse than labelling people, as Oscar Wilde definitely didn’t say, and that’s not labelling people.

And there’s only one thing worse than pumping people full of drugs… (an inquiry was told).

4. Getting over the mind brain problem

What it looks like inside your mind.

One of the biggest barriers to tackling Depression is getting hung up on the Mind / Body, or more specifically the Mind / Brain problem. Its the mind part that’s the issue. As soon as the word ‘mental’ comes into play, people get all upset.

Its hard to adjust to the fact that we may be nothing more, or nothing less, than very clever machines. Its also hard to believe that consciousness can emerge gradually from a wiring network, providing that network is large enough.

Surely, if all you needed for consciousness was a massive wiring system, then British Telecom would be a god like super-creature bent on world domination. Hmm…

So can consciousness, or the mind, be considered a separate entity from the body? This argument still hangs heavily for many when they think about mental health problems.

The mind / brain issue did preoccupy philosophers for many centuries and still occupies a large section of Wikipedia. Some philosophers thought that mind and body were entirely separate devices. This idea is called ‘dualism’ and tends to persist in the way people think about the human control system.

If mind and body were different ‘dual’ entities altogether, like sound and light, then how could they interact? Some kind of transducer device, as proposed in the pineal gland by Descartes? Or simply, (cheating really) bringing God into it to solve the problem, God acting as a cosmic DJ, operating the twin turntables of mind and brain, making sure they were synchronised properly at all times?

(This school of thought was termed ‘occasionalism’ and probably did not influence the Faithless song ‘God is a DJ’ nor even Pink’s cover version. Pink was yet unknown in ninth century Iraq).

Glossing over Philosophy and Religion for a short moment, there is a lot to support the argument that the brain is a very sophisticated computer system.

For instance, nerve cells which make up the brain are long and thin and transmit electrical charge, just like wiring. The nerve pathways in the brain look a lot like the wiring loom in your Honda Civic. Damage to part of the wiring system, such as after a stroke, can clearly bring about symptoms, like loss of movement to a limb.

Higher up the brain, the nerve networks get more complicated and seem to provide for various different types of mental activity. There is the completely automatic type that controls basic physical functions like the operations of the lungs, heart and gut. Then there’s the largely automatic thinking system that does things like drive you to work and make toast. And then there is the reflective part of the mind that chooses what to think and do, or thinks it does, or you think it does.

Computer speak has given us a new ‘dualist’ model to consider, the division between hardware and software. Sometimes it can be helpful to think of the brain as the computer and the mind as the operating system. As an analogy it is both helpful and unhelpful.

The plus points are that factors such as social learning and experiences and memory can be seen as software, running within the brains basic wiring network, which starts off as a largely empty system and gradually fills up. The mind’s ability to process information and store it, or create actions, are similar to an operating system.

There is also a nice computer analogy to be made between the mind’s two main memory systems, long term and short term. Stored memory can be seen as similar to a computer’s hard drive, whereas short term or ‘working memory’ has features similar to RAM. Working memory is far more limited than long term and easily exceeded by multiple or complex tasks, such as chewing gum and walking at the same time.

Many memory problems, such as those found in Depression, occur within the process of moving memory between the two systems. Depression very often reduces the power of concentration, which is needed to retrieve information from the storage system, and also to file memories away.

Against the software / hardware model however is the following problem; the brain is not a fixed system like your PC or Mac. It can create, remove or change its physical structure as it goes along. The changes are not just electrical, as in hardware, or even just chemical – the brain is continually creating new connections. This is why the brain is called ‘Plastic’ – the term is used to mean flexible and open to structural change.

In babies and children there is a huge and continuous rebuilding program of nerve cells. In adults there is a much more limited program of nerve cell slum clearance but sadly not much in the way of inner city regeneration. Depressed people may lose their ability to generate new nerve connections in certain parts of the brain. In fact an attractive theory of antidepressant therapy (both drugs and psychological therapy) is that these may work by stimulating nerve cell growth in certain key areas.

And this brings us, a little early, to the punch line. Which is that structure and function are inseparable features of our control system. They are so interactive that it make no sense to identify two entities called Mind and Brain.

In practical thinking this dilemma presents itself frequently in thinking about mental disorders. For instance in thinking of some illnesses as either mind based or brain based. In particular illnesses that were once considered to be ‘psychosomatic’ such as bowel or fatigue syndromes. Within Fatigue Syndrome there have been heated arguments by some sufferers that they should not be regarded as mental health patients, even though CBT may well be very helpful, as it can be in ‘physical’ illnesses like chronic pain.

The law has frequently got itself into a pickle by trying to separate what is due to the mind and what is due to the brain. We have seen concepts such as ‘non insane automatism’ invented to illustrate this area. The newish Mental Capacity Act speaks of a disorder of ‘mind or brain’, to get over the possible argument about which one was disordered. Could one ever be disordered without affecting the other?

Within Education, we have seen concepts such as ‘Brain Based Learning’, or ‘Mind Brain Constructivism’ as it is more properly known. Here again the proponents are careful to use the term mind/brain as a portmanteau concept. Strangely, educators have been rather uncritical about the supposed ‘Brain’ aspects, such as improving food and water consumption for students. The ‘healthy mind in a healthy body’ notion has been about for a long time in schools. Before Michael Gove, and in fact before even Socrates, neither of whom would have seen the mind as a wiring loom.

One of the more interesting findings from Brain Imaging has been the recognition that psychotherapy may bring about structural brain changes. For instance, changes have been found to the mid-brain serotonin transporter system, after psycho-dynamic psychotherapy. A much larger number of studies have shown changes to nerve cell functioning during and after therapy.

It could be argued that these sorts of changes are not actually ‘causal’ but rather just a secondary indicator of mood change. Nevertheless, there is clearly a mood control system in the brain that is represented in physical structures.

So we have the Fatigue Syndrome lobby who resent being considered as having a mental health problem, and we have the ‘anti-psychiatry’ lobby who hate the so called ‘biological’ model of Depression.

The fatigue lobby would be delighted if one day a clear biological cause is shown for the illness – presumably then it becomes like MS or any other ‘proper’ illness?

And the anti- psychiatrists would be delighted if absolutely no biological change could be found in the brains of depressed people. They have been similarly delighted by the findings that antidepressants are not as effective as people used to think. Their response is not at all to suggest finding a more effective antidepressant, but rather to debunk the whole concept of Depression.

If you need to ask how can simple chemicals substances change the way people think and behave, then you have (wisely) not visited Nottingham city centre at 11pm. If you doubt that faults can occur in complicated electronic control systems, and that such faults are impossible to diagnose and treat, try using a 10 year old Beko washing machine. It has a mind of its own.

It seems the learning point is never to try and assign a problem to mind / or body, and always to recognise that the two are one. If that makes us just a brilliant machine or merely thirty nine dollars worth of chemicals dressed in a suit of similar value, so what?

Well, for one thing, less stigma, and less guilt. If we have defective mood control systems, whatever the basis, then this is a health problem and not shameful.

I was taught by Irish Nuns that ‘man thou art dust and to dust you will return’. (Its the kind of thing Rugby Forwards say to each other before a game). The dust cost less than thirty nine dollars in those days.

And if God is really acting as DJ, is he playing enough soul?

3. It looks a bit DIY

Experts – do we need them?

There are surprisingly restrictive laws to prevent you doing bits of wiring and plumbing around your own home. Anything gas related is particularly strict, needing someone who is CORGI registered.

If you replace your gas hob, despite the fact that you can turn the gas off with a big tap, that the hob uses a simple bayonet joint, that gas is very smelly in case of leaks, that you have watched the CORGI man do it several times, that you don’t intend to do it with a lighted cigarette behind your ear – despite all that, if you disconnect it yourself you will be placed in the Tower of London for 100 years and tortured every Tuesday. Your crime is that you thought you knew better.

Surprisingly, when it comes to helping people with health problems, things are much looser. There are professional bodies regulating the top end of the market – doctors, nurses, psychologists, but even here there is very little regulation of what types of therapy they actually do.

Lower down, blurring into the alternative therapy market, pretty much anything goes. This market is full of therapists who think they know better. Better, that is, than any evidence they can produce to support their work.

Its often fascinating, as a psychiatrist, to see how people have attempted to deal with mental health problems prior to ‘calling in’ the NHS.

We know people delay seeking medical advice for health problems. People tend to adjust to symptoms for a long while, often attributing them to random and coincidental events such as biological washing powder or a mystery virus.

Such accommodation to symptoms only breaks down if something happens – you notice specks of blood over your white piano keys, like Chopin; your mum makes you an appointment for the GP. Or you are arrested in a public place under section 136 of the mental health act and taken to a place of safety.

Before we get to the point of needing professional advice, how long have things been deteriorating? In the case of psychotic and depressed patients, we know they have been unwell on average for many months before seeing anyone for help.

Some events are so traumatic that the person goes straight to hospital without passing GO or collecting £200. But the majority of medical events develop slowly, more like accepting a £10 fine, or, like Mr Huhne, taking a chance card instead. The first part of any illness is usually in our own hands to manage.

That means we have to consider health issues within the reflective mind, however much that part of the mind wants to sweep them under the conscious carpet.

When it comes to mental health problems there are times when we need an objective person to give advice. Another person can be a vital source of insight. Often just talking to another person helps us reflect better. Before we tell another person we are on our own and at the mercy of the limited perspective of the single view.

Even after we have convinced ourselves, and maybe our mums, that we have a problem, we encounter barriers around the health care system. These have been built good and high to filter out the excess demand placed upon a free health system.

The ‘culture of fear’ that NHS-managementism has created extends downwards towards service providers and users.

Firstly there is a healthy scepticism about what motivates the NHS behind the scenes: 1. the nanny state; 2. targets that determine payments; 3. drug companies.

Then there are simple filters such as a permanently engaged phone line, KGB receptionists and a lack of appointments.

Perhaps more of a barrier for most people is just not knowing how to engage. What should you take to the doctor, how do you describe it, how do you present it? Should you take someone with you, should you write things down on a bit of paper, should you google it first?

Once into the mental health system we are very unlikely to find an ideal therapist we can relate to. One reason is that the demography of the NHS workforce nowhere near reflects the demography of the population it serves.

Another reason is the very small number of trained professionals relative to the number of people who suffer from mental illnesses.

For example, our GP has 2000 patients on average. Lets assume 3% of them (more later about the 3% issue) have severe depression – that’s already 60 people. Our local psychiatrist serves – again on average – 40,000 people. He or she will have a caseload of several hundred.

How many hours are there in a week? In the NHS, about 12, by the time we have allowed for bureaucratic intrusions, mandatory training, focus groups, and having our hair done.

Without wishing to denigrate anyone involved, or indeed undermine the foot-ware industry, the NHS mental health services are run on a shoestring. The negative halo effect that surrounds mental health issues also effects prioritisation and funding, relative to hotter specialities like Fever.

Having thought about all these barriers – starting with our own reluctance to think about our health, stigma, bureaucracy, shortages, shouldering our way into a system that feels like rush hour in Naples – its amazing that anyone gets treated at all.

Luckily, unlike with the CORGI fitter, a lot of it can be done by yourself. Often using equipment you can find in your own kitchen, such as another person.

But the first rule has to be: don’t think you know better (until you can prove it).

The second rule is: no cigarettes.

2. Where will the war take place?

The war against Depression begins with an attempt at building a strategy (unlike some recent wars I could mention).

Firstly we must identify the enemy. Then we must identify our resources. Then we must deploy our resources to where the enemy is weakest.

And we must look at where previous similar campaigns have come unstuck.

A few years ago, the UK Royal Colleges of Psychiatrists and GPs ran a campaign called ‘Defeat Depression’. Traditional campaigns designed to improve public health usually involve screening – trying to detect cases of the illness that have not been discovered. For a successful campaign the following ingredients are needed:

We have a way of discovering cases using some kind of test.

We have a treatment option to offer those found to be suffering.

The treatment option is effective enough to cover the costs of running the program.

The Defeat Depression campaign was based on the notion that a large number of depressed people were undiagnosed and suffering in relative silence. If they were diagnosed, using simple screening tests, they could be given antidepressants and/or therapy that would improve their condition.

Recent types of antidepressants such as selective serotonin re-uptake inhibitors, (SSRI) seemed to be effective, non – addictive and low in side effects. So the balance had tipped in favour of prescribing them, if not exactly spraying the countryside with them.

Sure enough, there has been an enormous increase in the diagnosis and treatment of depression in the UK. GPs use a screening tool called PHQ-9 to uncover cases. For moderate or severe depression, antidepressants are recommended, starting with an SSRI, either Fluoxetine (Prozac) or Citalopram (Cipramil).

Possibly, one day, SSRIs will become ‘over the counter’ remedies rather than prescription only. After all, you can now buy own – brand Ranitidine at hardware stores. Its not that long since Ranitidine was ‘Zantac’, and available only from proper doctors in white coats and half- moon glasses, probably after an endoscopic exam or barium x ray.

People used to warn that taking Ranitidine might mask the symptoms of more serious stomach problems, delay people seeking medical advice, and thus prove harmful. Such fears seem to have been overly pessimistic, but doctors and pharmacists are always going to want to steer the medicines trolley.

Making antidepressants freely available in Lidl, or Boots at least, might have a greater impact than any other measure, if we are seeking to get the greatest number of people on to antidepressant medication. Yet there has been no campaign to make this happen. Why?

Is it because antidepressants can be harmful if not carefully monitored? For instance they need to be taken for several weeks at least rather than as and when we feel like it.

Or is it because we are reluctant to see medication as the answer to Depression? Or maybe because existing antidepressants have a relatively poor benefit to risk ratio?

The defeat depression campaign attracted a fair amount of criticism behind the scenes. On the one hand there was something of a doubt over how effective antidepressants really were.

Also they had side effects that were troubling, some real and some imaginary. It was suggested that they could make some people more impulsive and – in the case of teenagers – more suicidal. Some of them seemed to have ‘discontinuation effects’ causing flu like symptoms a day or two after stopping treatment. Their effect of reducing libido was more common than people recognized.

People warned that the Depression concept was being stretched to include unhappiness, ‘medicalising’ peoples responses to social ills such as call centres and poor quality sausages .

Some people even went as far as suggesting the depression industry was part of a capitalist conspiracy to make people feel dissatisfied with their lot in life. It was alleged that such dissatisfaction would serve to fuel consumer demand and get the proletariat back on the treadmill of purposeless consumption, indebtedness and hard labour.

In the background, a few psychiatrists remained highly skeptical about the effectiveness of newer antidepressants, even preferring older drugs that had a better evidence base.

It looked to many as though the Royal Colleges had been swept along by the SSRI companies, without thinking the strategy through. Two favorite stereotypes for Psychiatrists are Dr Dippy and Dr Evil. So, not looking clever, and seeming to be in cahoots with drug companies, damaged our image. When the Prozac bubble burst within the liberal consensus, British psychiatry was badly splattered.

The most deadly germs are those that can change their form and structure. The same is probably true of terrorist organizations. By adapting to different situations they can often go undetected. Germs can pretend to be other organisms, or part of your own body.

Terrorists can pretend to be religious men. Gangsters can pretend to be politicians. A lot of it is down to packaging and presentation. Depression is an entity that resorts to camouflage in response to a conventional attack.

In response to the Defeat Depression campaign many people remained in denial. Few were convinced that Depression could be treated in the same way as a germ based illness. Few were convinced it was easy to identify and treat. And even fewer trusted psychiatrists and GPs to tackle the problem.

Lots more antidepressants were finding their way into our sewerage systems one way or another, (often cutting out the middle man), but was anyone much happier?

There is a lot of conflicting thinking about Depression – whether it exists within society, and whether it exists in an individual. It can hide within a heap of what looks like unhappiness. It can hide within what looks like a life crisis or drink problem. It can hide within a cranky view of the world.

Essentially, all this needs to be tackled on a personal level. Depression exists in individuals, not in towns or countries. All that matters is what Depression means for you.This means that the battle against Depression will take place mainly in your kitchen. Luckily, you choose the weapons.

At exactly 0600 we go over the wall.

1. The War on Depression Starts Today

Car parks can be beautiful if you look at them the right way

Don’t be frightened – it’s only a car park.

The War on Depression: where is the enemy weak?

These pages are mainly about Depression. The starting point is to understand how Depression comes about and the finishing point is dealing with it better.

As an individual psychiatrist it may not be possible to make much of an impact on the wider problem of Depression, which affects so many millions of people.

But there are many fronts to fight on, outside the hospital.

There are a few themes to these pieces. One is to do with how toxic modern life has become. One is to do with how the mind works and in particular how people make choices. And a third one is to explain how health systems such as the NHS operate for (or sometimes against) people with mental health problems.

However we regard Depression, as an illness, as wear and tear, as a reaction to loss or as a social barometer, there is always another perspective to take.

Rather than ask the question, ‘why do some people get depressed?’ we might just as well ask why everyone isn’t depressed all the time.

Lets get the bad news out of the way right now: people get older. Generally when they get older they get more ill, and (don’t say it, please) eventually die.

In some ways that fact, the D word, is a potential party – pooper, even when we are young and have a fabulous future to look forward to.

Worse than that, even younger people can get ill, and they certainly can be subjected to terrible events (such as school).

Its been said that all political careers end in failure. Partly that’s because of the scoring system in politics, which tends to be ‘sudden death’, either by way of an election, or by way of sudden death.

But the same is not true of most sportsmen and women, who are somehow able to retire at the right time. In boxing, that’s while the brain is still working. For the rest of us, its a matter of recognising changes and adjusting to them .

If we adjust too much too quickly we are hypochondriacs and wimps. If we adjust too late we are foolhardy and in denial.

Life is very complicated and dangerous and a lot of us don’t make it, either in terms of quality or quantity of life. Some of us spend a lot of time ‘off the road,’ on the hard shoulder of life, but that doesn’t make us burned out ruins.

In seeing Depression as a wear and tear or stress related illness, we are not really explaining it very much. I prefer to see it as a natural phenomenon that is also an enemy, like rust. Or, at times, Gravity. Black ice. Wind. Electricity. Biscuits. Etc

All necessary but dangerous when out of control.

Depression happens when the system that controls mood is defective. The system has failed to calibrate correctly, or feed back on itself, or stay at a level. Most of what we do in treating Depression, one way or another, is to try and get the control system working better.

Often that’s a matter of seeing the situation differently: reflecting, reframing, resetting, recalibrating. (4 Rs. Much better than 3.)

The way we see Depression, in its widest contexts, affects very much how we deal with it. Depression is a very isolating experience, both in terms of reduced social contact, and reduced range and quality of thinking.

But if Depression was inevitable, or even an overwhelming likelihood, why is it that many people never get depressed, whatever happens? Do they have a very sophisticated chemical control mechanism? Or do they reflect upon the world in a different way? Or do they have some protective factor, like a guardian angel?

After this length of time, over 50 years of antidepressant and drug therapy, it doesn’t look as though we have a breakthrough solution, at least by way of a tablet. It would be nice to think a magic bullet would get discovered, much as saltwater killed the Triffids in one of the Day of the Triffids films, or the Common Cold killed the Martians in War of the Worlds.

While we wait to find the enemy’s weak spot, we continue to fight on all fronts. Depression’s Achilles Heal is in fact the thing that makes it strong, its incoherence as a diagnostic concept.

Could Depression fall apart under the weight of its own complexity, like the coalition government?

More to follow.

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