There are important geographical variations in the prevalence of depression, and these can in large part be accounted for by socio-cultural factors. In traditional societies, human distress is more likely to be seen as an indicator of the need to address important life problems, rather than as a mental disorder requiring professional treatment. For this reason, the diagnosis of depression is correspondingly less common. Some linguistic communities do not have a word or even a concept for ‘depression’, and many people from traditional societies with what may be construed as depression present with physical complaints such as headache or chest pain rather than with psychological complaints. Punjabi women who have recently immigrated to the UK and given birth find it baffling that a health visitor should pop round to ask them if they are depressed. Not only had they never considered the possibility that giving birth could be anything other than a joyous event, but they do not even have a word with which to translate the concept of ‘depression’ into Punjabi!

In modern societies such as the UK and the USA, people talk about depression more readily and more openly. As a result, they are more likely to interpret their distress in terms of depression, and less likely to fear being stigmatised if they seek out a diagnosis of the illness. At the same time, groups with vested interests such as pharmaceutical companies and mental health experts promote the notion of saccharine happiness as a natural, default state, and of human distress as a mental disorder. The concept of depression as a mental disorder may be useful for the more severe and intractable cases treated by hospital psychiatrists, but probably not for the majority of cases, which, for the most part, are mild and short-lived, and easily interpreted in terms of life circumstances, human nature, or the human condition.

Another (non-mutually exclusive) explanation for the important geographical variations in the prevalence of depression may lie in the nature of modern societies, which have become increasingly individualistic and divorced from traditional values. For many people living in our society, life can seem both suffocating and far removed, lonely even and especially amongst the multitudes, and not only meaningless but absurd. By encoding their distress in terms of mental disorder, our society may be subtly implying that the problem lies not with itself, but with them. However, thinking of the milder forms of depression in terms of an illness can be counterproductive, as it can prevent people from identifying and addressing the important life problems that are at the root of their distress.

Adapted from The Meaning of Madness.

A person’s beliefs, attitudes, and values (henceforth, ‘beliefs’) are stored in his brain in the form of nerve cell pathways. Over time and with frequent use, these neural pathways become increasingly worn in, such that it becomes difficult to alter them and so the beliefs that they correspond to. If these beliefs are successfully challenged, the person begins to suffer from ‘cognitive dissonance’, which is the psychological discomfort that results from holding two or more inconsistent or contradictory beliefs (‘cognitions’) at the same time. To reduce this cognitive dissonance the person may either (1) adapt his old beliefs, which is difficult or (2) maintain the status quo by justifying or ‘rationalising’ his new beliefs, which is not so difficult and therefore more common. The ego defence of rationalisation involves the use of feeble but seemingly plausible arguments either to justify one’s beliefs (‘sour grapes’) or to make them seem ‘not so bad after all’ (‘sweet lemons’). ‘Sour grapes’ is named after one of the fables attributed to Aesop, The Fox and the Grapes.

One hot summer’s day a Fox was strolling through an orchard till he came to a bunch of Grapes just ripening on a vine which had been trained over a lofty branch. ‘Just the thing to quench my thirst’, quoth he. Drawing back a few paces, he took a run and a jump, and just missed the bunch. Turning round again with a One, Two, Three, he jumped up, but with no greater success. Again and again he tried after the tempting morsel, but at last had to give it up, and walked away with his nose in the air, saying: ‘I am sure they are sour.’

In the case of Aesop’s fox, the cognitive dissonance arises from the cognitions ‘I am an agile and nimble fox’ and ‘I can’t reach the grapes on the branch’, and the rationalisation, which is a form of ‘sour grapes’, is ‘I am sure the grapes are sour’. Had the fox chosen to use ‘sweet lemons’ instead of ‘sour grapes’, he might have said something like, ‘In any case, there are far juicier grapes in the farmer’s orchard.’ Another example of rationalisation is the student who fails his exams and who blames the examiners for being biased. In this case, the cognitive dissonance arises from the cognitions ‘I am an intelligent, capable person’ and ‘I failed my exams’, and the rationalisation, which is once again a form of ‘sour grapes’, is ‘I am sure the examiners are biased’. Had the student chosen to use ‘sweet lemons’ instead of ‘sour grapes’, he might have said something like, ‘In any case, failing my exams has given me more time to study / gain experience / examine my career options / enjoy student life.

One of the most famous examples of rationalisation comes from Leon Festinger’s book of 1956, When Prophecy Fails, in which Festinger discusses his experience of infiltrating a UFO doomsday cult whose leader had recently prophesised the end of the world. When the end of the world failed to materialise, most of the cult’s members dealt with the cognitive dissonance that arose from the cognitions ‘the leader prophesised that the world is going to end’ and ‘the world did not end’ not by abandoning the cult or its leader, but by introducing the rationalisation that the world had been saved by the strength of their faith.

Human beings are not rational, but rationalising animals. If they find it frightening to think and painful to change, this is in large part because thinking and changing represent major threats to the beliefs that make up their sense of self. Given this state of affairs, any tectonic shift in a person’s outlook is only ever going to occur incrementally and over a long period of time. Moreover, such a tectonic shift is likely to be provoked by an important deterioration in the person’s circumstances which overwhelms his ego defences and leaves him with no alternative but to adopt the depressive position. In Remembrance of Things Past, the early 20th century novelist Marcel Proust tells us, ‘Happiness is good for the body, but it is grief which develops the strengths of the mind.’

Adapted from The Art of Failure: The Anti Self-Help Guide

One of the central tenets of the Western worldview is that one should always be engaged in some kind of outward task. Thus, the Westerner structures his time – including, sometimes, even his leisure time – as a series of discrete programmed activities which he must submit to in order to tick off from an actual or virtual list. One needs only to observe the expression on his face as he ploughs through yet another family outing, yet another cultural event, or yet another gruelling exercise routine to realise that his aim in life is not so much to live in the present moment as it is to work down a never-ending list. If one asks him how he is doing, he is most likely to respond with an artificial smile, and something along the lines of, ‘Fine, thank you – very busy of course!’ In many cases, he is not fine at all, but confused, exhausted, and fundamentally unhappy. In contrast, most people living in a country such as Kenya in Africa do not share in the Western worldview that it is noble or worthwhile to spend all of one’s time rushing around from one task to the next. When Westerners go to Kenya and do as they are wont to do, they are met with peels of laughter and cries of ‘mzungu’, which is Swahili for ‘Westerner’. The literal translation of ‘mzungu’ is ‘one who moves around’, ‘to go round and round’, or ‘to turn around in circles’.

The 20th century psychoanalyst Melanie Klein called it the manic defence: the tendency, when presented with uncomfortable thoughts or feelings, to distract the conscious mind either with a flurry of activity or with the opposite thoughts or feelings. A general example of the manic defence is the person who spends all of his time rushing around from one task to the next like the mzungu; other, more specific, examples include the socialite who attends one event after another, the small and dependent boy who charges around declaiming that he is Superman, and the sexually inadequate adolescent who laughs ‘like a maniac’ at the slightest intimation of sex. It is important to distinguish this sort of ‘manic laughter’ from the more mature laughter that arises from suddenly revealing or emphasising the ridiculous or absurd aspects of an anxiety-provoking person, event, or situation. Such mature laughter enables a person to see a problem in a more accurate and less threatening context, and so to diffuse the anxiety that it gives rise to. All that is required to make a person laugh is to tell him the truth in the guise of a joke or a tease; drop the pretence, however, and the effect is entirely different.

In short, laughter can be used both to reveal the truth or – as in the case of the manic defence – to conceal it or to block it out. Indeed, the essence of the manic defence is to prevent feelings of helplessness and despair from entering the conscious mind by occupying it with opposite feelings of euphoria, purposeful activity, and omnipotent control. This is no doubt why people feel driven not only to mark but also to celebrate such depressing things as entering the workforce (graduation), getting ever older (birthdays), and even – more recently – death and dying (‘Halloween’). The manic defence may also take on more subtle forms, such as creating a commotion over something trivial; filling every ‘spare moment’ with reading, study, or on the phone to a friend; spending several months preparing for Christmas or some civic or sporting event; seeking out status or ‘celebrity’ so as to be a ‘somebody’ rather than a ‘nobody’ like everybody else; entering into baseless friendships and relationships; even, sometimes, getting married and having children.

In Virginia Woolf’s novel of 1925, Mrs Dalloway, one of several ways in which Clarissa Dalloway prevents herself from thinking about her life is by planning unneeded events and then preoccupying herself with their prerequisites – ‘always giving parties to cover the silence’. Everyone uses the manic defence, but some people use it to such an extent that they find it difficult to cope with even short periods of unstructured time, such as holidays, weekends, and long-distance travel, which at least explains why airport shops are so profitable. As Oscar Wilde put it, ‘To do nothing at all is the most difficult thing in the world, the most difficult and the most intellectual.’

Adapted from The Art of Failure: The Anti Self-Help Guide

Psyche in the temple of love

In 2008, just 6% of candidates sitting Paper 1 of the MRCPsych exam were UK graduates, evidence if any were needed that recruitment into psychiatry is facing an unprecedented crisis.

In my experience, most medical students enjoy learning about mental illness and talking to mentally ill people, who often have a refreshing knack for saying things exactly how they are. In a fit of inspiration, some medical students tell me that psychiatry is the only specialty that enables them to think about themselves, about other people, and about life in general. They also like the lifestyle: an hour for each patient, ‘special interest’ days, protected time for teaching, light on calls from home, and guaranteed career progression. In medicine they might treat yet another anonymous case of asthma, chest pain, or pulmonary oedema. In surgery they might do one knee replacement after another, up until the day they retire or collapse. But in psychiatry there can be no factory line, no standard procedure, and no mindless protocol: each patient is unique, and each patient has something unique to return to the psychiatrist. I often come across those same students again, months or sometimes years later. After the smiles and the niceties, it transpires that they are no longer so interested in psychiatry. So what happened?

The students are never too sure, but I think I have an idea. Whilst I was a medical student in London, an American firm offered me a highly paid job as a strategy consultant in their Paris office. So I gladly left medicine, and the many inconveniences of working in (and increasingly ‘for’) the NHS. I had a great time in Paris, but the job itself turned out to be more about dealing with personality disorders than about having good ideas. I quit after six months and freelanced as an English tutor to high-flying executives, bankers, venture capitalists, and such like. As my clients already spoke good English and merely wanted to improve their fluency, all I had to do was to make conversation with them. My lessons often turned into something akin to psychotherapy, as I realised that I could make my clients open their hearts and minds simply by listening to them speak. Although they seemed to have everything in life, they were actually deeply unhappy, and had rarely stopped to ask themselves why. I wanted to find out why, so I decided to go back to the UK, do my house jobs, and specialise in psychiatry. I had always been far too ‘ambitious’ to consider psychiatry, but by then it had become clear that I didn’t want to pursue a career that didn’t allow me to think and feel, and to relate to others and to the world in a genuine and meaningful way. There are not many such jobs, but psychiatry – along with general practice, teaching, academia, and the clergy – is certainly one of them, and is even, arguably, their archetypal form.

The following year whilst going about my house jobs I put up with all sorts of abuse from my colleagues in medicine and surgery. One of the other house officers, by then a good buddy, took me aside one day and said with an alcoholic mixture of concern and disdain: ‘Why do you want to go into psychiatry? You’re a good doctor. Can’t you see you’re wasting your talents?’ It became very clear, first, that the stigma that people with a mental disorder are made to feel also extends to the doctors who look after them; and, second, that this stigma emanates most strongly from the medical profession itself, mired as it is in middle class preoccupations and prejudices and, as a whole, far too grounded in neurosis not to be terrified of psychosis.

Of course, it is simply not true that psychiatry is ‘a waste of talent’. The term ‘psychiatry’ was first used 200 years ago in 1808, in a 188-page paper by Johann Christian Reil. He argued for the urgent creation of a medical specialty to be called ‘psychiatry’, and contended that only the very best physicians had the skills to join it. These physicians needed not only to have an understanding of the body, but also a much broader range of skills than standard physicians. Indeed, a psychiatrist can change a person’s entire outlook with a single sentence, so long as he can find the right words and the right time. No protocols, no high-tech equipment or expensive drugs, no pain or side-effects, and no complications or follow-up. Now that is talent, and one so great that I can only ever aim at it. And each time I fail, I always have medicine to fall back on.

Posted on 26/07/2010: A recent update on the recruitment crisis facing psychiatry can be found here.